At multiple fronts: Diabetes stigma and weight stigma in adults with type 2 diabetes.

AIM: The diabetes and obesity fields have called for attention to the harmful role of stigma in obesity and diabetes, especially given that little is known about the extent and nature of diabetes stigma facing adults with type 2 diabetes, or the experience of weight stigma in this population. This study addresses this research gap by examining the prevalence and demographic correlates of weight stigma and diabetes stigma in individuals with type 2 diabetes. METHODS: Adults (N = 1212, Mage  = 52) with type 2 diabetes living in the USA were recruited by a healthcare-oriented market research firm, and completed online questionnaires to assess their experiences with weight stigma and diabetes stigma, as well as their internalization of both forms of stigma. Rates of stigma and sociodemographic correlates (years with type 2 diabetes, age, education, income, gender, race and BMI) were examined. RESULTS: More than half of participants reported prior experiences of weight stigma, and 40-60% reported experiencing weight stigma in a healthcare context. Participants reported frequent experiences with diabetes-related stigma including blame and judgement, self-stigma and differential treatment. Women reported more weight stigma than men, and White women appeared particularly at risk for experiencing weight and diabetes related stigma relative to Black women. CONCLUSIONS: Individuals with type 2 diabetes reported higher rates of weight stigma than the general population, experienced high rates of diabetes-related stigma, and many internalized these forms of stigma. Increased attention to stigma reduction is essential to ensuring equitable care for individuals with type 2 diabetes.

Weight bias internalization in a commercial weight management sample: prevalence and correlates.

OBJECTIVE: Weight bias internalization (WBI) is associated with poor weight-related health. The purpose of this study was to identify the prevalence and correlates of WBI in a large sample of adults in a commercial weight management programme. METHODS: WW (the new Weight Watchers) members participated in an online survey. Participants (N = 18,769) completed the 10-item Weight Bias Internalization Scale - Modified (WBIS-M) and the Weight Self-Stigma Questionnaire (WSSQ). Participants reported details about weight-stigmatizing experiences, including the onset, frequency and distress, and interpersonal sources of weight stigma. Participants self-reported their demographics, weight history, and height and weight (to compute body mass index [BMI]). RESULTS: Weight bias internalization was relatively high compared with the general population (mean WBIS-M score = 4.3 ± 1.4; mean WSSQ total score = 35.2 ± 9.7). WBI was higher among participants who were female, younger and had higher BMIs (p < 0.001) and lower among those who were Black and were widowed or had a romantic partner (p < 0.001). Onset of weight stigma in childhood and young adulthood, and recent distress due to weight stigma, predicted higher WBI. Extended family and school sources of weight stigma had weaker associations with WBI than did other interpersonal sources. CONCLUSIONS: Weight bias was internalized by a significant proportion of adults enrolled in a commercial weight management programme. A phenotype of WBI includes demographic characteristics and the timing and sources of weight stigma.

Weight-based victimization from friends and family: implications for how adolescents cope with weight stigma.

BACKGROUND: Youth with overweight and obesity commonly experience weight-based victimization. The ways that these youth cope with victimization can adversely impact their health. Despite considerable evidence that family members and friends are common perpetrators of weight-based victimization, the relationships among different sources of victimization and coping responses of youth are unknown. OBJECTIVES: The present study examined the relationships between weight-based victimization from four sources (friends, peers, family members and teachers) and stigma-specific coping responses in adolescents using linear regression. METHODS: Adolescents (ages 13-18 years; N = 148) enrolled in a national weight loss camp completed questionnaires about demographics, weight bullying, sources of teasing and internalized weight bias. RESULTS: Teasing sources explained a large proportion of the variance in coping strategies for weight-based victimization. Weight teasing from friends was associated with greater frequency of negative emotions. Weight teasing from peers and friends were associated with greater frequency of coping via avoidance behaviours, while teasing from family was associated with fewer avoidance behaviours. Adolescents reported wanting more support from parents and stronger school policies to address weight-bullying. CONCLUSIONS: These results suggest associations between weight-teasing sources and coping mechanisms. Interventions should examine the role of coping strategies to protect against adverse health effects of weight-based victimization.

Weight bias among exercise and nutrition professionals: a systematic review.

Obesity affects approximately one-third of American adults. Recent evidence suggests that weight bias may be pervasive among both exercise and nutrition professionals working with adults who have obesity. However, the published literature on this topic is limited. This review aimed to (i) systematically review existing literature examining weight bias among exercise and nutrition professionals; (ii) discuss the implications of this evidence for exercise and nutrition professionals and their clients; (iii) address gaps and limitations of this literature; and (iv) identify future research directions. Of the 31 studies that met the criteria for this review, 20 examined weight bias among exercise professionals, of which 17 (85%) found evidence of weight bias among professionals practicing physical therapy (n = 4), physical education (n = 8) and personal/group fitness training (n = 5). Of 11 studies examining weight bias among nutrition professionals, eight (73%) found evidence of weight bias. These findings demonstrate fairly consistent evidence of weight bias among exercise and nutrition professionals. However, the majority of studies were cross-sectional (90%). Given that weight bias may compromise quality of care and potentially reinforce weight gain and associated negative health consequences in patients with obesity, it is imperative for future work to examine the causes and consequences of weight bias within exercise and nutrition professions using more rigorous study designs.

Weight bias internalization and health: a systematic review.

A robust literature has documented the negative health effects of being the target of weight bias. Weight bias internalization (WBI) occurs when individuals apply negative weight stereotypes to themselves and self-derogate because of their body weight. Compared with experiences of weight bias, less is known about the relationship between WBI and mental and physical health, although more literature on this topic has emerged in recent years. The current systematic review identified 74 studies assessing the relationship between WBI and health and interventions designed to reduce WBI and improve health. Over half of identified studies were published from 2016 to 2017. Results showed strong, negative relationships between WBI and mental health outcomes. Fewer studies have examined the relationship between WBI and physical health, and results were less consistent. Key directions for future research are highlighted, including the need for prospective and experimental studies with greater sample diversity.

Adolescent preferences for weight terminology used by health care providers.

BACKGROUND: In light of high rates of obesity and weight stigma in youth, the American Academy of Paediatrics recommends that paediatric health care professionals use appropriate, sensitive and non-stigmatizing language in communication about weight with youth. For these efforts to be effective, there is a need to identify weight-based language preferences among youth with overweight and obesity, as research in this area is scarce. OBJECTIVES: The present study provides a systematic assessment of youth perspectives of weight-based language used by providers. METHODS: Adolescents (ages 13-18 years; N = 148) enrolled in a national weight loss camp were surveyed about their preferences for words that health providers use to refer to their body weight. Adolescents completed an online survey and responded to a list of 16 words describing excess body weight, as well as questions assessing demographics, body mass index, and experienced as well as internalized weight stigma. RESULTS: Adolescents assigned low ratings to words like 'fat', 'large', 'obese' and 'extremely obese', indicating that they would not want providers to use these words when discussing their body weight. In contrast, words like 'weight problem', 'BMI' and 'plus size' were rated among the most preferred words for providers to use. Word preferences varied across gender, body mass index and extent of internalized weight stigma. CONCLUSIONS: These findings underscore the importance of acknowledging different word preferences among youth, and to avoid making assumptions about what words youth will feel most comfortable using in discussions about their body weight.

Missing the target: including perspectives of women with overweight and obesity to inform stigma-reduction strategies.

OBJECTIVE: Pervasive weight stigma and discrimination have led to ongoing calls for efforts to reduce this bias. Despite increasing research on stigma-reduction strategies, perspectives of individuals who have experienced weight stigma have rarely been included to inform this research. The present study conducted a systematic examination of women with high body weight to assess their perspectives about a broad range of strategies to reduce weight-based stigma. METHODS: Women with overweight or obesity (N = 461) completed an online survey in which they evaluated the importance, feasibility and potential impact of 35 stigma-reduction strategies in diverse settings. Participants (91.5% who reported experiencing weight stigma) also completed self-report measures assessing experienced and internalized weight stigma. RESULTS: Most participants assigned high importance to all stigma-reduction strategies, with school-based and healthcare approaches accruing the highest ratings. Adding weight stigma to existing anti-harassment workplace training was rated as the most impactful and feasible strategy. The family environment was viewed as an important intervention target, regardless of participants' experienced or internalized stigma. CONCLUSION: These findings underscore the importance of including people with stigmatized identities in stigma-reduction research; their insights provide a necessary and valuable contribution that can inform ways to reduce weight-based inequities and prioritize such efforts.

Adolescent preferences and reactions to language about body weight.

Over 30% of youth and adolescents have overweight or obesity, and health care providers are increasingly discussing weight-based health with these patients. Stigmatizing language in provider-patient communication about obesity is well documented and could be particularly detrimental to youth and adolescents. Although some research has examined preferences for weight-based terminology among adults, no studies have addressed these issues in youth populations. This study represents a preliminary and systematic investigation of weight-based language preferences among adolescents with overweight and obesity enrolled in a summer weight loss camp. Participants (N=50) indicated preferences for weight-based language and emotional responses to words that their family members used in reference to their body weight. Weight neutral terminology ('weight', 'body mass index') were most preferred, although some differences in word preferences emerged by the participants' gender. Boys preferred having their weight described as 'overweight' and 'heavy', while girls preferred the word 'curvy'. A large proportion of participants, particularly girls, reported experiencing sadness, shame, and embarrassment if parents used certain words to describe their body weight, which highlights the importance of considering the emotional impact of weight-based terminology. Providers may consider asking youth and adolescents for their preferences when discussing weight-based health.

Improving anti-bullying laws and policies to protect youth from weight-based victimization: parental support for action.

BACKGROUND: Weight-based bullying is a prevalent problem among youth with overweight and obesity, but remains neglected in existing policy-level strategies to address youth bullying. Parental support is an influential catalyst motivating political will for policy decisions affecting youth, but has received limited research attention. OBJECTIVES: To assess levels of, and predictors of, parental support for school-based policies and state/federal legal measures to address weight-based bullying in 2014 and 2015. METHODS: Identical online questionnaires were completed by two independent national samples of parents in 2014 and 2015 (N = 1804). RESULTS: Parental support for all policy actions was high (at least 81%) and significantly increased from 2014 to 2015 for legal measures that would a) require state anti-bullying laws to add protections against weight-based bullying, and b) enact a federal anti-bullying law that includes weight-based bullying. CONCLUSIONS: These findings can inform policy discourse about remedies for youth bullying, and suggest that parental support for improved legal protections against weight-based bullying is present, consistent, and strong.

Legislating for weight-based equality: national trends in public support for laws to prohibit weight discrimination.

The prevalence of weight discrimination in the United States has led to increasing calls for legal measures to address weight-based inequities on a broader scale. This study examined public support in 2014 and 2015 for three proposed laws prohibiting weight discrimination, and compared findings with public attitudes towards the same laws from 2011 to 2013. An online survey was completed by a diverse national sample of US adults (N=2411) in June-July of 2014 and 2015 to assess their support for anti-discrimination legislation. Public support increased for the anti-discrimination laws from 2014 to 2015, and at least 71% of participants expressed support for each of the laws in both years. Compared with public support documented in 2011-2013, there was a significant increase in support in 2014-2015 for legislation to extend disability protections to individuals with obesity and for laws that would include body weight in existing state civil rights statutes. Consistently, high levels of support (78%) were documented across this 5-year period for laws to address weight-based discrimination in employment. As public approval is a powerful catalyst motivating political will needed to make policy changes, these findings provide important insights and implications for advancing policy-level discourse about remedies for weight discrimination.

Cross-national perspectives about weight-based bullying in youth: nature, extent and remedies.

BACKGROUND: No cross-national studies have examined public perceptions about weight-based bullying in youth. OBJECTIVES: To conduct a multinational examination of public views about (i) the prevalence/seriousness of weight-based bullying in youth; (ii) the role of parents, educators, health providers and government in addressing this problem and (iii) implementing policy actions to reduce weight-based bullying. METHODS: A cross-sectional survey of adults in the United States, Canada, Iceland and Australia (N = 2866). RESULTS: Across all countries, weight-based bullying was identified as the most prevalent reason for youth bullying, by a substantial margin over other forms of bullying (race/ethnicity, sexual orientation and religion). Participants viewed parents and teachers as playing major roles in efforts to reduce weight-based bullying. Most participants across countries (77-94%) viewed healthcare providers to be important intervention agents. Participants (65-87%) supported government augmentation of anti-bullying laws to include prohibiting weight-based bullying. Women expressed higher agreement for policy actions than men, with no associations found for participants' race/ethnicity or weight. Causal beliefs about obesity were associated with policy support across countries. CONCLUSIONS: Across countries, strong recognition exists of weight-based bullying and the need to address it. These findings may inform policy-level actions and clinical practices concerning youth vulnerable to weight-based bullying.

Visual portrayals of obesity in health media: promoting exercise without perpetuating weight bias.

Health education campaigns for preventing and reducing obesity often contain weight-stigmatizing visual content, which may have unintended negative health consequences. The goal of the present research was to identify non-stigmatizing visual content for health education materials that can promote exercise among people of diverse weight statuses. An online sample of 483 US women viewed: (i) a woman with obesity portrayed stereotypically; (ii) a woman with obesity exercising; (iii) a woman with obesity portrayed neutrally; or (iv) a lean woman exercising. Race of the models pictured was randomized (White or Black). Participants completed measures of weight bias and exercise behavior and attitudes, and provided information about their weight status. Analysis of covariance revealed that responses to stereotypical and exercise images varied by participant weight status. Across participants, neutral obesity portrayals elicited lower expressions of weight-biased attitudes and higher reports of exercise liking/comfort. Among non-overweight participants, images portraying women with obesity stereotypically or counter-stereotypically produced greater endorsement of negative stereotypes than control, lean images. No effects of model race were found. These findings suggest that the public responds differently to visual portrayals of obesity depending on weight status, and neutral portrayals may be an effective route toward promoting exercise without perpetuating stigma.

A multinational examination of weight bias: predictors of anti-fat attitudes across four countries.

BACKGROUND/OBJECTIVES: As rates of obesity have increased throughout much of the world, so too have bias and prejudice toward people with higher body weight (that is, weight bias). Despite considerable evidence of weight bias in the United States, little work has examined its extent and antecedents across different nations. The present study conducted a multinational examination of weight bias in four Western countries with comparable prevalence rates of adult overweight and obesity. METHODS: Using comprehensive self-report measures with 2866 individuals in Canada, the United States, Iceland and Australia, the authors assessed (1) levels of explicit weight bias (using the Fat Phobia Scale and the Universal Measure of Bias) and multiple sociodemographic predictors (for example, sex, age, race/ethnicity and educational attainment) of weight-biased attitudes and (2) the extent to which weight-related variables, including participants' own body weight, personal experiences with weight bias and causal attributions of obesity, play a role in expressions of weight bias in different countries. RESULTS: The extent of weight bias was consistent across countries, and in each nation attributions of behavioral causes of obesity predicted stronger weight bias, as did beliefs that obesity is attributable to lack of willpower and personal responsibility. In addition, across all countries the magnitude of weight bias was stronger among men and among individuals without family or friends who had experienced this form of bias. CONCLUSIONS: These findings offer new insights and important implications regarding sociocultural factors that may fuel weight bias across different cultural contexts, and for targets of stigma-reduction efforts in different countries.

Parental support for policy measures and school-based efforts to address weight-based victimization of overweight youth.

BACKGROUND: Despite research documenting weight-based victimization (WBV) toward overweight youth in the school setting, little work has examined parental perceptions of this problem or potential policy strategies to help protect youth who are teased and bullied about their weight. This study assessed parental reports of WBV in youth and parental support for potential measures to address this problem, including implementation of school-based resources, policies, and state and federal laws. METHODS: A national sample of parents in the United States (N=919) completed an online questionnaire about their perceptions of WBV in the school setting, including whether or not their child had experienced or witnessed WBV. Parents were also asked the degree to which they would support potential policy strategies to address WBV in schools, including school-based policies and state and federal laws to address weight-based bullying in youth. RESULTS: Parents perceived overweight youth to be vulnerable to WBV at school, but less than half of parents perceived schools to be prepared to deal with instances of WBV. Parents (both with and without overweight children) agreed that schools should implement anti-bullying policies that include specific protections for students who are overweight or obese, increase resources available to youth who experience WBV at school, and promote awareness about this problem. Over two-thirds of parents agreed that state anti-bullying laws should include specific protections against weight-related bullying. CONCLUSION: These findings indicate that there is substantial support from parents, both with and without overweight children, to implement a range of policy measures to address this WBV at the school, state, and federal level.

The effect of physicians' body weight on patient attitudes: implications for physician selection, trust and adherence to medical advice.

BACKGROUND: Research has documented negative stigma by health providers toward overweight and obese patients, but it is unknown whether physicians themselves are vulnerable to weight bias from patients. PURPOSE: This study assessed public perceptions of normal weight, overweight or obese physicians to identify how physicians' body weight affects patients' selection, trust and willingness to follow the medical advice of providers. METHODS: An online sample of 358 adults were randomly assigned to one of three survey conditions in which they completed a questionnaire assessing their perceptions of physicians who were described as normal weight, overweight or obese. Participants also completed a measure of explicit weight bias (Fat Phobia Scale) to determine whether antifat attitudes are associated with weight-related perceptions of physicians. RESULTS: Respondents reported more mistrust of physicians who are overweight or obese, were less inclined to follow their medical advice, and were more likely to change providers if the physician was perceived to be overweight or obese, compared to normal-weight physicians who elicited significantly more favorable reactions. These weight biases remained present regardless of participants' own body weight. Inspection of interaction effects revealed opposing effects of weight bias between the obese/overweight and normal-weight physician conditions. Stronger weight bias led to higher trust, more compassion, more inclination to follow advice, and less inclination to change doctors when the physician was presented as normal weight. In contrast, stronger weight bias led to less trust, less compassion, less inclination to follow advice and higher inclination to change doctors when the physician was presented as obese. CONCLUSIONS: This study suggests that providers perceived to be overweight or obese may be vulnerable to biased attitudes from patients, and that providers' excess weight may negatively affect patients' perceptions of their credibility, level of trust and inclination to follow medical advice.

The influence of a defendant's body weight on perceptions of guilt.

OBJECTIVE: To investigate the influence of a defendant's weight on simulated jurors' perceptions of guilt. DESIGN AND METHODS: Participants were 471 lean and overweight adults (mean body mass index: 25.34±5.91) who read a vignette describing a case of check fraud while viewing one of four images of the alleged defendant (a lean male, a lean female, an obese male or an obese female). Participants rated the defendant's culpability on a 5-point Likert scale and completed measures of anti-fat attitudes. RESULTS: Male respondents endorsed greater overall weight bias than females (F (1470)=23.815, P<0.01, η(2)=0.048). A three-way interaction was detected between participant sex, defendant sex and defendant weight on perceptions of guilt such that when the defendant was female, male participants were significantly more likely to find her guilty if she was obese than if she was lean (guilt ratings=4.05±0.83; 3.31±1.03, respectively; F(1467)=5.935, P=0.015, R(2)=0.060). In addition, lean male participants were significantly more likely to believe that the obese female defendant met criteria for check fraud, and indicated greater belief she would be a repeat offender, compared with the lean female defendant (t(90)=2.081, P=0.040; t(90)=2.395 P=0.019, respectively). There were no differences in perceptions of guilt or responsibility between the obese male and the lean male defendants. CONCLUSION: The results of this novel study indicate that both weight and gender of a defendant may affect juror perceptions of guilt and responsibility.

Weight bias among UK trainee dietitians, doctors, nurses and nutritionists.

BACKGROUND: Trainee dietitians, nutritionists, nurses and doctors will direct the future of obesity treatment and prevention. To do so effectively, they must be willing and able to engage empathically with overweight and obese people. The present study aimed to assess weight bias among UK trainee healthcare professionals and to investigate the factors predicting weight bias, both static and potentially modifiable. METHODS: A self-completed questionnaire collected data on demographics, weight and height, the Fat Phobia Scale (F-scale), and the Beliefs about Obese People (BOAP) scale from 1130 students. RESULTS: Overall, participants demonstrated significant levels of fat phobia [F-scale score mean (SD) = 3.8 (0.5)]. Only 1.4% of participants could be said to have expressed 'positive or neutral attitudes' (i.e. achieved a F-scale score ≤ 2.5). Hierarchical multiple regression revealed that lower fat phobia (as measured by the F-scale) was uniquely predicted by a higher self-reported body mass index, being on the Nursing BSc course and a stronger perception that obesity is not under a person's control (as measured by the BOAP scale). CONCLUSIONS: There are unacceptable levels of weight bias among UK students training to become nurses, doctors, nutritionists and dietitians. The results of the present study suggest that a promising approach for future interventions would be the provision of balanced education about the controllability of obesity, focusing upon genetic and environmental factors, as well as diet and exercise.

Fighting obesity or obese persons? Public perceptions of obesity-related health messages.

OBJECTIVE: This study examined public perceptions of obesity-related public health media campaigns with specific emphasis on the extent to which campaign messages are perceived to be motivating or stigmatizing. METHOD: In summer 2011, data were collected online from a nationally representative sample of 1014 adults. Participants viewed a random selection of 10 (from a total of 30) messages from major obesity public health campaigns from the United States, the United Kingdom and Australia, and rated each campaign message according to positive and negative descriptors, including whether it was stigmatizing or motivating. Participants also reported their familiarity with each message and their intentions to comply with the message content. RESULTS: Participants responded most favorably to messages involving themes of increased fruit and vegetable consumption, and general messages involving multiple health behaviors. Messages that have been publicly criticized for their stigmatizing content received the most negative ratings and the lowest intentions to comply with message content. Furthermore, messages that were perceived to be most positive and motivating made no mention of the word 'obesity' at all, and instead focused on making healthy behavioral changes without reference to body weight. CONCLUSION: These findings have important implications for framing messages in public health campaigns to address obesity, and suggest that certain types of messages may lead to increased motivation for behavior change among the public, whereas others may be perceived as stigmatizing and instill less motivation to improve health.

Motivating or stigmatizing? Public perceptions of weight-related language used by health providers.

BACKGROUND: Research demonstrates that health providers express negative attitudes toward overweight and obese patients that can be conveyed through weight-related language, yet little is known about people's perceptions of weight-related language used by providers. The current study examined public preferences and perceptions of weight-based terminology used by health-care providers to describe excess weight. METHOD: A national sample of American adults (N=1064) completed an online survey to assess perceptions and preferences associated with 10 common terms to describe body weight. Participants rated how much they perceived each term to be desirable, stigmatizing, blaming or motivating to lose weight (using five-point Likert scales), and how they would react if stigmatized by their doctor's reference to their weight. RESULTS: The terms 'weight' (3.43, 95% confidence interval (CI) 3.35-3.50) and 'unhealthy weight' (3.24, 95% CI 3.15-3.33) were rated most desirable, and the terms 'unhealthy weight' (3.77, 95% CI 3.69-3.84) and 'overweight' (3.51, 95% CI 3.43-3.58) were rated most motivating to lose weight. The terms 'morbidly obese', 'fat' and 'obese' were rated as the most undesirable (95% CI 1.61-2.06), stigmatizing (95% CI 3.66-4.05) and blaming (95% CI 3.62-3.94) language used by health providers. Notably, participant ratings were consistent across socio-demographic variables and body weight categories. A total of 19% of participants reported they would avoid future medical appointments and 21% would seek a new doctor if they felt stigmatized about their weight from their doctor. CONCLUSION: This study advances our understanding of why individuals prefer particular weight-related terms, and how patients may react if their provider uses stigmatizing language to refer to their weight. It also offers suggestions for practical strategies that providers can use to improve discussions about weight-related health with patients.