Weight bias: a call to action

Examining weight bias attitudes and obesity beliefs among undergraduate students

Objective: This cross-sectional study examined the weight bias attitudes and obesity beliefs of health science (HS), nursing, and pre-medicine undergraduate students. Methods: Using snowballing and convenience sampling strategies, students (N = 139) completed an online survey, including a 24-item Antifat Attitudes Scale (AFAS) and eight-item Belief About Obese Persons (BAOP) scale. Results: HS students have higher weight bias than nursing and pre-medicine students combined (M = 43.45, SD = 10.75), t(137) = -2.45, p = .016). A negative correlation exists between AFAS and BAOP suggesting high weight bias influences a belief that obesity is controllable. Gender positively predicted weight bias attitudes (ß = -11.43, t = -4.33, p < .001) and obesity beliefs (ß = 3.75, t = 3.01, p = . 003). Conclusions: Findings confirm that HS students have weight bias attitudes. This supports undergraduate curricular changes on obesity etiology that may improve treatment plans of individuals who are obese.

Relationships Between Chronic Illness, Body Mass Index, and Patient-Provider Communication

Little is known about how higher-weight patients experience patient-provider communication, particularly among those with chronic illness. This study uses quantitative analytical methods and nationally representative data to determine how patient-provider communication is affected when patients have one or more chronic illnesses, as well as if patient BMI has a moderating effect on this association. Pearson correlation and multivariate logistic regression were both used to determine the significance of these associations. A significant, negative, relationship was found between overall patient-provider communication and patient chronic illness status, but no significant relationship was found between respondent BMI and patient-provider communication. There was no observable moderation effect of respondent BMI on the relationship between their number of chronic illnesses and the perceived quality of the patient-provider communication they experienced. From this study there is evidence that patients with multiple chronic illness experience worse communication with their health care providers which could be due to numerous types of bias. More research is needed to better understand if and how weight and other bias affects outcomes for chronically ill patients. Research implications include improving the comprehensiveness of nation-wide surveys that measure health care quality to include improved measures of perceived bias, including weight bias, and patient-provider communication, as these are complex, multi-factorial concepts.

Exploring weight bias and negative self-evaluation in patients with mood disorders: insights from the BodyTalk Project

Background

Negative body image and adverse body self-evaluation represent key psychological constructs within the realm of weight bias (WB), potentially intertwined with the negative self-evaluation characteristic of depressive symptomatology. Although WB encapsulates an implicit form of self-critical assessment, its exploration among people with mood disorders (MD) has been under-investigated. Our primary goal is to comprehensively assess both explicit and implicit WB, seeking to reveal specific dimensions that could interconnect with the symptoms of MDs.

Methods

A cohort comprising 25 MD patients and 35 demographically matched healthy peers (with 83% female representation) participated in a series of tasks designed to evaluate the congruence between various computer-generated body representations and a spectrum of descriptive adjectives. Our analysis delved into multiple facets of body image evaluation, scrutinizing the associations between different body sizes and emotionally charged adjectives (e.g., active, apple-shaped, attractive).

Results

No discernible differences emerged concerning body dissatisfaction or the correspondence of different body sizes with varying adjectives. Interestingly, MD patients exhibited a markedly higher tendency to overestimate their body weight (p = 0.011). Explicit WB did not show significant variance between the two groups, but MD participants demonstrated a notable implicit WB within a specific weight rating task for BMI between 18.5 and 25 kg/m2 (p = 0.012).

Conclusions

Despite the striking similarities in the assessment of participants' body weight, our investigation revealed an implicit WB among individuals grappling with MD. This bias potentially assumes a role in fostering self-directed negative evaluations, shedding light on a previously unexplored facet of the interplay between WB and mood disorders.

The Weight Stigma Heat Map: A tool to identify weight stigma in public health and health promotion materials

ISSUES ADDRESSED

Public health campaigns and health promotion endeavours have been criticised for perpetuating weight stigma by reinforcing misinformation and using deficits-based narratives about larger-bodied people. The aim of this project was to develop a 'heat map' tool to appraise existing health policy and resources for elements that promote weight stigma.

METHODS

Ten themes were identified from literature using inductive analytic review methodology including pictorial/photographic representation, weight-health beliefs, body weight modifiability and financial concerns. Each theme was divided into four appraisal categories: the demonstration of weight stigma (via negative stereotyping, prejudice or discrimination that limits access to opportunities or services), weight bias (via presenting smaller bodies as normal/natural/healthy/good/desirable), bias-neutral (via representation of people of all shapes and sizes and accurate and nuanced health information about larger-bodied and smaller-bodied people) and finally an anti-stigma approach (via use of strengths-based narratives and overtly positive representation of and leadership by larger-bodied people).

RESULTS

A colour coding schema (the 'heat map') to visualise stigmatising elements across materials and a scoring system was devised for future quantitative evaluation. To demonstrate the use of the Weight Stigma Heat Map (WSHM), the Australian National Obesity Strategy 2022-2032 was appraised.

CONCLUSIONS

It is likely that weight stigmatisation is an important but under-recognised factor influencing the effectiveness of campaigns and interventions promoting behaviour change. SO WHAT?: Public health and health promotion professionals should consider using the WSHM as a framework for the development of less stigmatising policies, campaigns and resources and to direct reviews of existing materials.

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.

Erasing stigmas through storytelling: why interactive storytelling environments could reduce health-related stigmas

In this article we describe how designers can apply storytelling to reduce health-related stigmas. Stigma is a pervasive problem for people with illnesses, such as obesity, and it can persistently hinder coping, treatment, recovery, and prevention. Reducing health-related stigma is complex because it is multi-layered and self-perpetuating, leading to intertwined vicious circles. Interactive storytelling environments can break these vicious circles by delimiting the narrative freedom of stigma actors. We theoretically explain the potential of interactive storytelling environments to reduce stigma through the following seven functions: 1) expose participants to other perspectives, 2) provide a protective frame, 3) intervene in daily conversations, 4) persuade all stigma actors, 5) exchange alternative understandings, 6) elicit understanding and support for stigma victims, and 7) support stigma victims to cope with stigmatization. We elaborate on these functions through a demonstration of an interactive storytelling environment against weight stigma. In conclusion, this article is a call on designers for health and wellbeing, scientists, and practitioners from various disciplines to be sensitive to the pervasiveness of stigma and to collaboratively create destigmatizing storytelling environments.

Transforming the landscape of obesity education - The Canadian obesity education competencies

Background

With ongoing gaps in obesity education delivery for health professions in Canada and around the world, a transformative shift is needed to address and mitigate weight bias and stigma, and foster evidence-based approaches to obesity assessment and care in the clinical setting. Obesity Canada has created evidence-based obesity competencies for medical education that can guide curriculum development, assessment and evaluation and be applied to health professionals' education programs in Canada and across the world.

Methods

The Obesity Canada Education Action Team has seventeen members in health professions education and research along with students and patient experts. Through an iterative group consensus process using four guiding principles, key and enabling obesity competencies were created using the 2015 CanMEDS competency framework as its foundation. These principles included the representation of all CanMEDS Roles throughout the competencies, minimizing duplication with the original CanMEDS competencies, ensuring obesity focused content was informed by the 2020 Adult Obesity Clinical Practice Guidelines and the 2019 US Obesity Medication Education Collaborative Competencies, and emphasizing patient-focused language throughout.

Results

A total of thirteen key competencies and thirty-seven enabling competencies make up the Canadian Obesity Education Competencies (COECs).

Conclusion

The COECs embed evidence-based approaches to obesity care into one of the most widely used competency-based frameworks in the world, CanMEDS. Crucially, these competencies outline how to address and mitigate the damaging effects of weight bias and stigma in educational and clinical settings. Next steps include the creation of milestones and nested Entrustable Professional Activities, a national report card on obesity education for undergraduate medical education in Canada, and Free Open Access Medication Education content, including podcasts and infographics, for easier adoption into curriculum around the world and across the health professions spectrum.

Diabetes stigma and weight stigma among physicians treating type 2 diabetes: Overlapping patterns of bias

AIMS

Adults with type 2 diabetes (T2D) report experiencing stigma across multiple settings, including stigmatizing interactions with their healthcare providers. However, research examining physician biases toward patients with T2D is scarce. Identifying stigma-related barriers in diabetes care is essential to prevent providers' biases from impairing health care delivery. This study assessed attitudes towards individuals with T2D and obesity among physicians who treat T2D.

METHODS

Physicians specializing in internal medicine or endocrinology (n=205) completed a series of online questionnaires assessing their attitudes towards patients with T2D and obesity, and their attributions of controllability and blame of individuals with T2D and obesity.

RESULTS

While 85% of physicians felt professionally prepared and confident to treat patients with T2D, 1/3 reported being repulsed by patients with T2D and view them as lazy (39%), lacking motivation (44%), and non-compliant with treatment (44%). Many witnessed professionals in their field making negative comments about patients with T2D (44%). Physicians endorsed worse levels of bias towards patients with obesity than T2D, but differences were small.

CONCLUSIONS

Findings highlight the need for stigma reduction interventions for physicians addressing both T2D and obesity. Research assessing the effects of T2D stigma on quality of patient care and health outcomes is needed.

Acceptability of an Online Module Addressing Weight Bias: Perspectives and Attitudes of Undergraduate Health Students and Instructors

Weight bias and discrimination are highly pervasive and harmful to Canadians with higher weights. Researchers and practitioners who deliver, evaluate, and advise on dietary and weight-related interventions may inadvertently perpetuate weight bias through their work; however, trainees in these fields rarely have access to weight bias education within their applied health programs. This study evaluated the acceptability of an online educational weight bias module developed for undergraduate students enrolled in health courses. The intervention included a pre-recorded 20-minute online module with prompts for reflection or discussion, a self-assessment quiz, as well as a separate module and range of resources for instructors. Overall, 211 students from applied health courses and 4 instructors completed an online survey querying the module's delivery, impact, and relevance. Students agreed that the module provided useful information (82%), was easy to understand (97%), and was the right length (75%), but reported wanting more interactivity and engagement with the content. Instructors found the module engaging and useful and expressed interest in additional resources and support for weight bias education. Future research should explore the impact of weight bias education on students' weight-related attitudes and perceptions as well as feasibility and relevance of online features such as multimedia tools.

The prevalence and practice impact of weight bias among New Zealand registered dietitians

AIM

This study explored demographics and three characteristics of registered dietitians-optimism, perfectionism, and weight bias and whether they affect three components of dietetics practice-dietetics assessment, dietetics recommendations, and dietitian's perception of the client's success.

METHODS

A self-administered questionnaire was completed by 92 registered dietitians and student dietitians in New Zealand to assess explicit weight bias. [Correction added on 27 January 2023, after first online publication: in the preceding sentence, '109 registered dietitians' has been updated to '92 registered dietitians'.] Participants were randomised to receive a case study for a condition unrelated to weight accompanied by a photo of a woman with either a smaller or a larger body. Participants then assessed the client based on data provided, provided recommendations, and rated their perception of the client.

RESULTS

Mean (±SD) scores indicated mild fatphobia (2.63±0.39) in participating dietitians. Dietitians presented with the photo of a larger client assessed the client to have lower health and were more likely to provide unsolicited weight management recommendations. Additionally, dietitians rated the larger client as less receptive and motivated, and less likely to understand the recommendations adequately, with a lower ability to comply with and maintain these recommendations.

CONCLUSIONS

Dietitians and student dietitians in New Zealand may practise in a manner that could be perceived as influenced by negative implicit weight bias, despite the explicit fatphobia scale scores assessing only mild fatphobia. Further research examining the extent of the problem in New Zealand, how it impacts client outcomes, and possible solutions are required.

Predictors of support for anti-weight discrimination policies among Canadian adults

Introduction

Weight discrimination of individuals with overweight or obesity is associated with adverse mental and physical health. Weight discrimination is prevalent in many sectors such as within workplaces, where individuals with overweight and obesity are denied the same opportunities as individuals with lower weight status, regardless of performance or experience. The purpose of this study was to understand the Canadian public's support or opposition of anti-weight discrimination policies and predictors of support. It was hypothesized that Canadians will show support of anti-weight discrimination policies to some extent.

Methods

A secondary analysis was conducted on a previous cross-sectional sample of Canadian adults (N = 923, 50.76% women, 74.4% White) who responded to an online survey assessing weight bias and support of twelve anti-weight discrimination policies related to societal policies (e.g., implementing laws preventing weight discrimination) and employment-related policies (e.g., making it illegal to not hire someone due to their weight). Participants completed the Causes of Obesity Questionnaire (COB), the Anti-Fat Attitudes Questionnaire (AFA) and the Modified Weight Bias Internalization Scale (WBIS-M). Multiple logistic regressions were used to determine predictors of policy support.

Results

Support for policies ranged from 31.3% to 76.9%, with employment anti-discrimination policies obtaining greater support than societal policies. Identifying as White and a woman, being over the age of 45 and having a higher BMI were associated with an increased likelihood of supporting anti-weight discrimination policies. There were no differences between the level of support associated with attributing obesity to behavioral or non-behavioral causes. Explicit weight bias was associated with a reduced likelihood of supporting 8/12 policies. Weight Bias Internalization was associated with an increased likelihood of supporting all societal policies but none of the employment policies.

Conclusions

Support for anti-weight discrimination policies exists among Canadian adults, and explicit weight bias is associated with a lower likelihood of supporting these policies. These results highlight the need for education on the prevalence and perils of weight discrimination which may urge policy makers to consider weight bias as a form of discrimination that must be addressed. More research on potential implementation of anti-weight discrimination policies in Canada is warranted.

"I was bullied for being fat in every situation, in every outfit, at every celebration": A qualitative exploratory study on experiences of weight-based oppression in Qatar

Introduction

Weight-based oppression (WBO) has been documented as a widespread phenomenon in Western countries and is associated with a range of psychological, physiological, and behavioral harms. Research on weight-based oppression is largely absent from the Arab region.

Methods

We conducted a qualitative exploratory study using semi-structured in-depth interviews to examine the internalized attitudes, values, and beliefs related to body weight, and experiences of external weight-based oppression of 29 staff, faculty, and students at Qatar University.

Results

Thematic analysis revealed six major themes on the characteristics of internalized WBO, and the nature, timing, source, extent, and impact of external WBO. WBO was regarded as so common in the Arab culture as to be normative, with damaging exposure to WBO beginning in early childhood.

Conclusion

WBO in the Arab region is an important and unrecognized public health issue. Programs to reduce WBO should be developed in all sectors.

"It's Not the Stereotypical 80s Movie Bullying": A Qualitative Study on the High School Environment, Body Image, and Weight Stigma

BACKGROUND

Schools are crucial for preventing negative health outcomes in youth and are an ideal setting to address weight stigma and poor body image. The current study sought to examine and describe the nature of weight stigma and body image in adolescents, ascertain aspects of the school environment that affect body image, and identify recommendations for schools.

METHODS

We conducted 24 semi-structured interviews with students at 2 high schools in 2020. Qualitative data were analyzed using inductive coding and an immersion/crystallization approach.

RESULTS

Students did not report weight discrimination or harmful body image messaging from teachers or administrators. Physical education (PE) class and dress codes were 2 instances where covert weight stigma appeared. The most common forms of peer weight stigma reported were weight-based teasing and self-directed appearance critiques. Students recommended that schools eliminate dress codes, diversify PE activities, address body image issues in school, and be cognizant of teasing within friend groups.

CONCLUSIONS

Weight stigma presents itself in unique ways in high school settings. Schools can play a role in reducing experiences of weight stigma and negative body image. Weight-related teasing within friend groups was common and may not be captured in traditional assessments of bullying. More nuanced survey instruments may be needed.

Weight self-stigma and engagement among obese students in a physical education class

BACKGROUND

This is a cross-sectional in design. It involves the mediating effects of basic psychological need satisfaction in relation to the moderating effects of teacher autonomy support regarding weight self-stigma's effect on engagement among obese students in physical education classes.

METHODS

This study includes 165 Chinese high school obese students [mean age, 16.84 (±0.147) years], comprising 93 males (56.63%) and 72 females (43.63%), with a mean body mass index (BMI) of 30.453 (SD = 2.426). Participants completed the weight self-stigma questionnaire, basic psychological need satisfaction questionnaire, teacher autonomy support questionnaire, and student engagement questionnaire.

RESULTS

Weight self-stigma and engagement among obese students were mediated by basic psychological need satisfaction. Moreover, the mediated effect of basic psychological need satisfaction was moderated by teacher autonomy support.

CONCLUSION

Weight self-stigma and basic psychological need satisfaction are the antecedents influencing the engagement of obese students. Notably, weight self-stigma not only directly blocks the engagement of obese students but also their engagement by hindering the acquisition of basic psychological need satisfaction. Teacher autonomy support can significantly reduce the negative impact of weight self-stigma on basic psychological need satisfaction and significantly promote engagement. Therefore, by promoting their physical education engagement, physical education teachers should strengthen the application of their supportive autonomous teaching strategies to help obese students meet their basic psychological needs.

Weight stigma in patients with overweight and obesity: validation of the Italian Weight Self-Stigma Questionnaire (WSSQ)

PURPOSE

This study aimed to explore the factorial structure of the Italian Weight Self-Stigma Questionnaire (WSSQ) (Study1); and to test structural validity, internal consistency, test-retest reliability, and measurement invariance of the questionnaire across gender, Body Mass Index (BMI), age and occurrence of previous hospitalization for obesity (Study2).

METHODS

At admission into a hospital-based program for weight reduction and rehabilitation, 150 inpatients with overweight/obesity (68% females) completed the WSSQ (Study1). In Study2, in addition to the WSSQ, 446 inpatients (61.9% females) completed the Weight Bias Internalization Scale (WBIS), the Body Uneasiness Test (BUT), and the Center for Epidemiologic Studies Depression Scale (CES-D). A subsample of 40 patients also re-completed the WSSQ at discharge from the hospital.

RESULTS

The Italian WSSQ showed good overlap with the original factorial structure (Study1) and results were confirmed in Study2. Test-retest reliability and convergent validity showed adequate values. Measurement invariance revealed that WSSQ was perfectly invariant across both BMI and the occurrence of previous hospitalizations for obesity. In both studies, the internal consistency of the questionnaire was deemed acceptable.

CONCLUSIONS

The Italian WSSQ is a valid, reliable, and invariant tool for the assessment of weight-related self-stigma among patients with overweight/obesity. Future studies should assess its longitudinal invariance as well as its responsiveness to weight reduction treatments.

LEVEL OF EVIDENCE

V, descriptive study.

The consequences of a weight-centric approach to healthcare: A case for a paradigm shift in how clinicians address body weight

Current healthcare is weight-centric, equating weight and health. This approach to healthcare has negative consequences on patient well-being. The aim of this article is to make a case for a paradigm shift in how clinicians view and address body weight. In this review, we (1) address common flawed assumptions in the weight-centric approach to healthcare, (2) review the weight science literature and provide evidence for the negative consequences of promoting dieting and weight loss, and (3) provide practice recommendations for weight-inclusive care.

'I'm usually being my own doctor': women's experiences of managing polycystic ovary syndrome in Canada

BACKGROUND

Polycystic ovary syndrome (PCOS) is a complex, chronic condition characterized by anovulation, polycystic ovarian morphology and hyperandrogenism that requires lifelong management. To reduce the risk of comorbidity and to manage symptoms, lifestyle management and pharmaceuticals such as oral contraceptives are the most common forms of treatment and should be tailored to the individual patient. The literature to date has shown PCOS patients to experience widespread dissatisfaction with the amount and quality of information they receive from providers, along with lower levels of trust in physicians. Little is known about the lived experiences of women managing PCOS in Canada, across age groups.

METHODS

In-depth remote interviews explored women's lived experiences managing PCOS and the barriers and facilitators they encountered in their management journeys. Data were analyzed using thematic analysis and interpretive description methodology.

RESULTS

Twenty-five in-depth, telephone interviews conducted with participants (aged 18-63 y) across Canada revealed participants lacking sufficient information and guidance from physicians, especially in primary care. Areas in need of more guidance included lifestyle management and mental health. Lack of empathy and weight bias among physicians were also perceived by participants. Older participants received little guidance on treatment options postmenopause. Loss of trust and withdrawal from seeking medical care were prominent themes, along with greater self-reliance on self-management, including self-educating and self-experimenting with treatments.

CONCLUSIONS

Most women in this study were frustrated with the level of involvement and information provision from their doctors. Key recommendations are identified for the provision of care to younger and older patients with PCOS. Improved education for physicians may be needed to improve the quality of healthcare provision for PCOS.

Addressing Weight Bias in the Cisgender Population: Differences between Sexual Orientations

(1) Background: Weight bias (WB) is an implicit psychological construct that can influence attitudes, beliefs, body experience, and evaluation of specific psychopathology relationships. Sexual orientation has played a crucial role in developing and maintaining psychiatric conditions linked to body evaluation, but few studies have evaluated possible connected biases. Thus, the paper aims to assess potential relationships between sexual orientation and WB, looking at potential roles in specific psychopathology; (2) Methods: A total of 836 cisgender subjects participated in an online survey, aged between 18 and 42 years old. Two specific aspects of WB were evaluated with validated scales about beliefs about obese people and fat phobia. Demographic variables, as well as depression and eating concerns were evaluated; (3) Results: Gay men and bisexual women showed higher levels of fat phobia, depression, and eating concerns. Regression analysis showed that sexual orientation significantly predicted fat phobia (p < 0.001) and beliefs about obese people (p = 0.014); (4) Conclusions: This study confirms the vulnerability of gay men and bisexual women to cognitive bias about their own bodies, showing a potential vulnerability about body and weight concerns.

A model of weight-based stigma in health care and utilization outcomes: Evidence from the learning health systems network

Objective

Obesity is stigmatized and people with obesity report experiencing stigmatizing situations when seeking health care. The implications of these experiences are not well understood. This study tests an indirect effects model of negative care experiences as an intermediate variable between obesity and care avoidance/utilization and switching primary care doctors.

Methods

A survey was completed by 2380 primary care patients in the Learning Health Systems Network (LHSNet) Clinical Data Research Network with a BMI >25 kg/m2. Measures included scales assessing stigmatizing situations, perceived patient-centered communication, perceived respect, having delayed needed care, and having looked for a new primary doctor in the past 12 months. Sequential and serial indirect effects of care experiences and respect in the association between BMI and care utilization outcomes was modeled.

Results

The hypothesized model was supported by findings. The associations between BMI and delaying needed care (OR = 1.06, p < 0.001) and attempting to switch primary doctors (OR = 1.02, p = 0.04) was mediated by both stigmatizing situations experienced in a health care context and lower patient-centered communication. Lower perceived respect mediated the association between care experiences and utilization outcomes.

Conclusions

People with higher BMIs may avoid care or switch doctors as a result of stigmatizing experiences and poor communication with doctors. These outcomes may contribute to morbidity in people with obesity if they delay or avoid care for health concerns when symptoms first present.

Fear of fatness and desire for thinness as distinct experiences: A qualitative exploration

OBJECTIVE

The pursuit of thinness and fear of gaining weight have been found to play an important role in eating disorder symptomatology. While these dimensions have typically been considered conjointly, emerging evidence suggests they may be distinct dimensions. The aim of this study was to explore the subjective experiences of fear of fatness and drive for thinness in young women with body image concerns.

METHOD

Young women endorsing weight concerns (N = 29, mean age = 20.86, SD = 2.70 years) were interviewed and asked to describe an experience of fear of fat and drive for thinness, respectively.

RESULTS

Qualitative analysis was conducted and identified four themes: (1) precipitating events; (2) physiological, emotional, cognitive, and proprioceptive experiences; (3) coping strategies; and (4) sociocultural influences. While similarities emerged, the experiences of fear of fatness, and of drive for thinness also evidenced clear differences situating the former in the context of fear-based avoidance patterns, and the latter in approach-based reward models.

DISCUSSION

These findings provide additional support for the usefulness of considering fear of fat and drive for thinness as distinct constructs. Further research examining the contributions of each of these constructs to eating pathology is warranted.

"Negative Things That Kids Should Never Have to Hear": Exploring Women's Histories of Weight Stigma in Physical Activity

Scholars have proposed that cumulative experiences of anti-fat bias and stigma contribute to detrimental physical activity experiences, as well as social and health inequities. The objective of this research was to explore how enacted weight stigma experiences are constructed and impact women's physical activity experiences long term. Eighteen women who identified as having had negative experiences related to their body weight, shape, or size in physical activity contexts participated in semistructured interviews. Using reflexive thematic analysis, four themes were identified: (a) norms of body belonging, (b) distancing from an active identity, (c) at war with the body, and (d) acts of resistance. These findings deepen understandings of how historical experiences of weight stigma can have longstanding consequences on physical activity cognitions, emotions, and behaviors. To equitably promote physical activity, it is imperative that movement spaces (e.g., fitness centers, sport organizations) both target anti-fat stigma and adopt weight-inclusive principles.

Anti-fat attitudes of Nutrition undergraduates in Brazil toward individuals with obesity

Abstract Obesity-related prejudice and discrimination may have a source in health professionals and students. The objective was to assess anti-fat attitudes among Brazilian nutrition undergraduates who reported demographic data, weight, height and responded the Antifat Attitudes Test (AFAT) and the Brazilian Silhouette Scales to assess body image satisfaction and perception. Total and subscales of AFAT scores were compared among categories using the Mann-Whitney U test. Associations of participants’ characteristics with the AFAT were analyzed using multiple linear regression. Total AFAT score was positively associated with male sex (ß: .13; p < .001), age (ß: .06; p < .001), educational institution outside capital (ß: .03; p < .05), private institutions (ß: .08; p < .001); and negatively associated with income (ß: -.05; p = .006), participants who perceived themselves with increased BMI (ß: -.15; p < .001) and those at the third year of course (ß: -.05; p = .041). Subscales scores were positively associated with male sex and age; and negatively associated with those who perceived themselves heavier. They have anti-fat attitudes especially if they were man, older, from private institutions, are at the beginning of the course, and have lower household income - and less weight bias if they perceived with increased BMI.

The role of weight stigma in weight regain in bariatric surgery

Obesity is highly stigmatized, and individuals who undergo bariatric surgery are subject not only to weight stigma, but also to stigma related to the procedure itself. Patients lost to follow-up after surgery make estimating the amount of regain occurring after surgery difficult, and often patients fail to follow up due the shame of weight regain. Patients report difficulty following the diet necessary to maintain weight loss. Additionally, when they seek support after surgery, they often encounter stigmatizing messaging related to weight. Weight bias internalization, weight stigma, and stigma about having the surgery all contribute to feelings of social isolation, disordered eating, and reduced motivation to engage in physical activity. In this chapter, we present evidence for the impact of stigma on bariatric surgery outcomes and discuss the behavioral, physiological, and emotional processes that contribute to weight regain.

What are weight bias measures measuring? An evaluation of core measures of weight bias and weight bias internalisation

Research exploring weight bias and weight bias internalisation (WBI) is grounded upon several core measures. This study aimed to evaluate whether operationalisations of these measures matched their conceptualisations in the literature. Using a 'closed card-sorting' methodology, participants sorted items from the most used measures into pre-defined categories, reflecting weight bias and non-weight bias. Findings indicated a high degree of congruence between WBI conceptualisations and operationalisations, however found less congruence between weight bias conceptualisations and operationalisations, with scale-items largely sorted into non-weight bias domains. Recommendations for scale modifications and developments are presented alongside a new amalgamated weight bias scale (AWBS).

The Case for a Health at Every Size Approach for Chronic Disease Risk Reduction in Women of Color

The conventional approach to chronic disease management in women of color is a dieting-for-weight-loss approach, which has not been proven to be effective. The purpose of this article is to highlight the shortcomings of the dieting-for-weight-loss approach and demonstrate the potential efficacy of the Health at Every Size approach when working with women of color to prevent and address chronic diseases. The article's areas of focus are weight stigma, bias, and size discrimination; the implications of differing weight perceptions and motivations for change; and weight as the primary determinant of health and biological factors affecting weight.

Women's Experiences with a Mindful Eating Program for Binge and Emotional Eating: A Qualitative Investigation into the Process of Change

Objectives: Mindfulness-based interventions (MBIs) have been shown to reduce engagement in disordered eating behaviors, although how these interventions engender change remains unclear. The objective of this exploratory qualitative study was to describe the experiences and perceived attitudinal and behavioral changes of women participating in a mindful eating program. Design: Focus group discussions were held with women participating in a community-based mindful eating program for binge and emotional eating. A semistructured interview guide was used to explore participants' conceptualizations of mindfulness-based attitudinal and behavior change, as related to food, eating, and body image. The focus group discussions were audio-recorded, transcribed, and analyzed using thematic analysis to identify salient concepts. Settings/Location: Focus group discussions were held at the Center for Mindfulness at the University of Massachusetts Medical School (UMMS) (United States). Participants: A sample of nine women who were enrolled in the mindful eating program at UMMS for problems with self-reported binge and/or emotional eating participated in this study. Results: Four themes were constructed that described a process of mindfulness-based behavior change, including (1) Learning Through Self-Awareness, (2) Self-Empowerment, (3) Mindful Choice-Making, and (4) Resilient Self-Care. An overarching description of the participants' perceived attitudinal and behavior changes was developed: "unforced freedom of choice, emerging from embodied awareness." Conclusions: These findings suggest that MBIs reduce may disordered eating behaviors through empowering women to make positive choices about food, eating, and coping, without focusing on weight control. Future research is needed to examine whether these findings replicate in larger and more diverse samples, and how they can be used to optimize and implement eating-specific MBIs in community-based settings.

Body-related attentional bias as mediator of the relationship between body mass index and body dissatisfaction

Body image disturbance, consisting of an affective (body dissatisfaction) and perceptual (body distortion) component, is not only found in eating disorders, but is also present in healthy individuals, affecting their psychological well-being and everyday life. A higher body mass index is associated with higher body dissatisfaction, whereas results in relation to body distortion are mixed. Furthermore, body dissatisfaction is associated with a weight-related attentional bias. This study aimed to investigate the mediating role of a weight-related attentional bias in the relationship between body mass index and body image disturbance. Forty-one college women took part in a virtual reality and eye tracking procedure, in which the illusion of owning a virtual avatar with their body measurements was induced. During this procedure, body-related attentional bias was measured and afterwards body image disturbance was assessed. Mediation analysis revealed that weight-related attentional bias mediated the relationship between body mass index and body dissatisfaction (but not distortion). These findings suggest that modifying weight-related attentional bias would be a useful treatment target for improving body dissatisfaction. In addition, virtual reality technology could serve as an innovative method for modifying attentional bias in an ecologically valid way. HIGHLIGHTS: This Virtual Reality and Eye-Tracking study expands our knowledge about the relation between body mass index, body-related attention and body image disturbances. The results suggest that attentional bias towards weight-related body parts mediates the relation between BMI and body dissatisfaction. On the contrary, the relation between BMI and body distortion was not significant.

Concept of overweight bias among healthcare professionals: An evolutionary concept analysis

The aim of this concept analysis was to identify the attributes of overweight bias among healthcare providers (HCPs) and create a clear definition to guide the recognition of overweight bias among HCPs. Settings within the healthcare system are not exempt from bias and the stigmatization of persons with obesity. Overweight bias among HCPs may negatively impact health care and health outcomes. Rodger's evolutionary method was used to guide this concept analysis. The databases CINAHL Plus with Full Text, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, MEDLINE, and PsycINFO were searched. The analysis provided clarification of the concept to facilitate HCP self-awareness of overweight bias. A definition of the concept of overweight bias among HCPs is provided along with its attributes, antecedents, and consequences.

The Impact of Obesity and Lifestyle on the Immune System and Susceptibility to Infections Such as COVID-19

Background: COVID-19 is a global challenge to healthcare. Obesity is common in patients with COVID-19 and seems to aggravate disease prognosis. In this review we explore the link between obesity, chronic disease, lifestyle factors and the immune system, and propose societal interventions to enhance global immunity. Search Strategy and Selection Criteria: We performed three literature searches using the keywords (1) coronavirus AND comorbidities, (2) comorbidities AND immune system, and (3) lifestyle factors AND immune system. Results were screened for relevance by the main author and a total of 215 articles were thoroughly analyzed. Results: The relationship between obesity and unfavorable COVID-19 prognosis is discussed in light of the impact of chronic disease and lifestyle on the immune system. Several modifiable lifestyle factors render us susceptible to viral infections. In this context, we make a case for fostering a healthy lifestyle on a global scale. Conclusions: Obesity, additional chronic disease and an unhealthy lifestyle interactively impair immune function and increase the risk of severe infectious disease. In adverse metabolic and endocrine conditions, the immune system is geared toward inflammation. Collective effort is needed to ameliorate modifiable risk factors for obesity and chronic disease on a global scale and increase resistance to viruses like SARS-CoV-2.

Responses of fitness center employees to cases of suspected eating disorders or excessive exercise

BACKGROUND

While exercise and physical activity are important parts of a healthy life, there is evidence that some individuals exercise to a degree which may jeopardize their health. These individuals may in some cases be exercising to lose weight or compensate binge eating episodes as part of an eating disorder. Others may experience an addiction-like relationship with exercise. Fitness center employees are ideally placed to observe these forms of unhealthy behavior, and are responsible for ensuring that clients do not put themselves at undue risk; however, to date, no study has addressed both eating disorders and excessive exercise. Therefore, the aim of our study is to determine whether these employees report incidences of these issues, and if they believe they can differentiate between them.

METHODS

One-hundred-and-forty fitness centers in the German-speaking regions of Switzerland were contacted. Of these, 99 employees (60 men, 39 women, M_age = 33.33 years, SD = 12.02) responded to an online questionnaire. The questionnaire briefly described the two issues of interest (eating disorders and excessive exercise), and then invited respondents to complete a number of questions detailing whether they had experience with these issues, and how they dealt with them.

RESULTS

Approximately 75% of the employees had suspected a client of having an eating disorder or exercising excessively, and 65% of these respondents confronted the client at least once. Interestingly, respondents reported clearly that they felt able to differentiate between the two types of disorder. Older respondents were significantly more likely to have suspicions and act on them. However, less than half of the respondents were aware of guidelines addressing this issue, and the majority desired more information about how to identify and address both disorders.

CONCLUSIONS

Swiss fitness center employees frequently encounter individuals who they suspect of exercising excessively, or suffering from an eating disorder. While they often confront these individuals, they would like more detailed information about how to manage this process. Given that both disorders can potentially lead to severe health consequences, a detailed description of symptoms, management techniques and resources should be a feature in all Swiss fitness center guidelines.

The perceived knowledge, skill and clinical practice of psychologists, naturopaths and fitness instructors when working with eating disorders

AIMS

When it comes to working with eating disorders (EDs), few studies have explored: the clinical practice; service provision barriers; and self-perceptions of knowledge/skill and the ability to detect EDs in practice against measured ability to do so, of common health providers including psychologists, naturopaths and fitness instructors.

METHODS

Of the 115 participants, 90.4% were female with a mean age of 40.77 years (SD = 10.80 years) and comprised: 35 psychologists, 50 naturopathic and 30 fitness practitioners. Participants completed a 23-item survey measuring clinical practice behaviours including assessment and early intervention services, practitioner service barriers, perceived ED knowledge and skill.

RESULTS

Only 1 in 20 indicated using standardized surveys to screen for EDs, with 72% indicating reluctance to universally screen clients, with a key barrier being that ED symptoms were typically not the presenting issue. For practitioners who missed detecting EDs in practice, 53.6% indicated this was because weight fell within the normal range or because the client did not present with an ED so they did not think to screen for one (39.29%). In terms of interventions, most (79%) were providing services to clients with EDs, with over one-third providing weight-loss advice, potentially contributing to a harmful weight-centric/dieting treatment approach. Despite most practitioners delivering services, 85.7% felt unable to treat some clients appropriately, primarily due to a lack of skill (52.6%).

CONCLUSIONS

Further training is imperative to improve universal screening and evidence-based early intervention practices, which may be particularly helpful for naturopaths and fitness instructors who more commonly perceived their knowledge to be low.

Experiences of the Pharmacy-Led Weight Management Service: Views of Service Providers in England

Obesity constitutes one of the main modifiable risks of developing cardiovascular disease. In the UK, in 2016, 30% of the adult population were obese (30% of females and 29% of males). Community pharmacies are ideally situated to offer weight management (WM) services, enabling individuals to control and lose their excess weight. This study aimed at exploring the views of the pharmacy-led WM service providers in England. Semi-structured interviews were conducted with 15 trained community pharmacists and pharmacy staff-11 (73.3%) from Kent, three (20%) from Kingston and Richmond and one (6.7%) from Hackney and City-offering the WM service, either owning or working in independent pharmacies or for pharmacy chains. All interviews were audio-recorded, transcribed and anonymised. The analysis was conducted using thematic analysis. Three themes emerged: training and support, barriers and approach. Interestingly, service providers (SP) stated that obesity is a tough topic to talk about: they found it difficult to start a conversation about it, even if they had received training to facilitate this role. Additionally, several barriers for running such a service were identified, such as lack of time, too much work pressure and too little advertising, which could potentially lead to poor sustainability of the service. SPs can effectively intervene in an individual's weight through the WM service that they offer. It is clear that further training should be provided in order for SPs to feel more comfortable in approaching and communicating with people and to increase the public's awareness of the pharmacy-led WM service, so as to ensure the service's sustainability.

Examining risk factors for overweight and obesity in children with disabilities: a commentary on Bronfenbrenner's ecological systems framework

Globally, overweight and obesity (OW/OB) levels are high among children, with rates surpassing the adult population. With such high pediatric OW/OB rates, it is imperative that risk factors are identified and explored. Thus, Davison and Birch developed an adapted framework, based on Bronfenbrenner's Ecological Systems Theory, which identifies and categorizes the factors in a child's life that put them at risk for OW/OB. While a socioecological perspective has been a useful tool for examining risk factors in typically developing pediatric populations, this holistic approach has not yet been applied to populations of children with disabilities, who are at an even higher risk of OW/OB than their typically developing peers. This commentary, therefore, explores Bronfenbrenner's Ecological Framework as applied to OW/OB by Davison and Birch, and critically examines its application to children with disabilities.

Communities for healthy living (CHL) - A family-centered childhood obesity prevention program integrated into Head Start services: Study protocol for a pragmatic cluster randomized trial

BACKGROUND

Childhood obesity is highly prevalent and carries substantial health consequences. Childhood obesity interventions have had mixed results, which may be partially explained by the absence of theory that incorporates broader family context and methods that address implementation challenges in low-resource settings. Communities for Healthy Living (CHL) is an obesity prevention program for Head Start preschools designed with careful focus on theory and implementation. This protocol paper outlines the design, content, implementation, and evaluation of CHL.

METHODS/DESIGN

CHL integrates a parenting program co-led by Head Start staff and parents, enhanced nutrition support, and a media campaign. CHL content and implementation are informed by the Family Ecological Model, Psychological Empowerment Theory, and Organizational Empowerment Theory. The intervention is directed by community-based participatory research and implementation science principles, such as co‑leadership with parents and staff, and implementation in a real world context. CHL is evaluated in a three-year pragmatic cluster-randomized trial with a stepped wedge design. The primary outcome is change in child Body Mass Index z-score. Secondary outcomes include children's weight-related behaviors (i.e., diet, physical activity, screen use, and sleep), parenting practices targeted at these behaviors (e.g., food parenting), and parent empowerment. The evaluation capitalizes on routine health data collected by Head Start (e.g., child height and weight, diet) coupled with parent surveys completed by subsamples of families.

DISCUSSION

CHL is an innovative childhood obesity prevention program grounded in theory and implementation science principles. If successful, CHL is positioned for sustained implementation and nationwide Head Start scale-up.

What's Weight Got to Do With It? Mental Health Trainees' Perceptions of a Client With Anorexia Nervosa Symptoms

This study examined the effect of client body mass index (BMI) on diagnostic impressions and perceptions of mental health trainees. Participants read a vignette of a mock female client presenting for treatment with symptoms of anorexia nervosa. Participants were randomly assigned to one of three conditions in which the client was described as “underweight,” “normal weight,” or “overweight.” Results revealed that participants assigned to the “underweight” condition diagnosed the client with anorexia nervosa or atypical anorexia nervosa more frequently than participants assigned to the “overweight” or “normal weight” conditions. There was no difference based on client BMI when the more general diagnosis of other specified feeding or eating disorder (OSFED; previously known as eating disorder not otherwise specified [EDNOS]) was included, however. Participants in the “overweight” and “normal weight” conditions recommended fewer therapy sessions for the client than participants in the “underweight” condition. Furthermore, participants more strongly endorsed weight-based stereotypes to describe the client when she was “overweight” than “normal weight” or “underweight.” Contrary to hypotheses, however, participants reported moderately positive attitudes toward treating the client regardless of BMI. These preliminary findings support initiatives aimed at providing training on weight stigma and eating disorders to mental health professionals.

Discordance Between Body Mass Index (BMI) and a Novel Body Composition Change Index (BCCI) as Outcome Measures in Weight Change Interventions

OBJECTIVE

A general assumption is that the body mass index (BMI) reflects changes in fat mass (FM). However, it fails to distinguish the type of weight that is lost or gained-fat mass (FM) or fat-free mass (FFM). The BMI treats both changes the same although they have opposite health consequences. The objective of this study was to propose a more precise measure, a body composition change index (BCCI), which distinguishes between changes in FM and FFM, and this study compares it with using the BMI as an outcome measure.

METHODS

Data were obtained from 3,870 subjects who had completed dual-energy x-ray absorptiometry (DEXA) total body scans at baseline and end-of-study when participating in a variety of weight-loss interventions. Since height remained constant in this adult cohort, changes in the BMI corresponded with scale weight changes (r = 0.994), allowing BMI changes to be converted to "lbs." to match the statistic used for calculation of the BCCI. The BCCI is calculated by scoring increases in FFM (lbs.) and decreases in FM (lbs.) as positive outcomes and scoring decreases in FFM and increases in FM as negative outcomes. The BCCI is the net sum of these calculations. Differences between scale weight changes and BCCI values were subsequently compared to obtain "discordance scores."

RESULTS

Discordance scores ranged from 0.0 lbs. to >30.0 lbs. with a mean absolute value of between the two measures of 7.79 lbs. (99% confidence interval: 7.49-8.10, p <0.00001), SD = 7.4 lbs. Similar discordance scores were also found in subgroups of self-reported gender, ethnicity, and age.

CONCLUSIONS

A significant difference of 7.79 lbs. was found between the BCCI and the BMI to evaluate the efficacy of weight loss interventions. If assessing changes in body composition is a treatment goal, use of the BMI could result in significantly erroneous conclusions.

Public and Healthcare Professionals' Knowledge and Attitudes toward Binge Eating Disorder: A Narrative Review

Binge eating disorder (BED) is characterized by recurrent binge eating and marked distress in the absence of inappropriate compensatory behaviors for weight control. BED is prevalent in men and women, is associated with elevated psychosocial and functional impairment, and is associated strongly with obesity and related medical comorbidities. The aim is to provide a brief, state-of-the-art review of the major and recent findings to inform educational and awareness campaigns, stigma reduction interventions, as well as current clinical practice and future research. A narrative approach was used to synthesize emerging literature on the public and healthcare professionals’ knowledge and attitudes toward individuals with BED in comparison to other eating disorders (EDs) or mental illness. A total of 13 articles were reviewed. Nine studies investigated community samples and four studies investigated healthcare professionals. The reviewed literature suggested that BED is perceived by the public as less impairing, less severe, and “easier-to-treat” than other EDs. Attitudes and beliefs reflecting perceived blameworthiness and lack of self-discipline were ascribed to vignettes with BED. Community studies indicated a low level of public awareness that BED constitutes a discreet eating disorder. The literature on healthcare professionals’ knowledge and attitudes toward BED remains very limited. The few existing studies suggest encouraging trends in recognition and diagnostic accuracy, yet there remains a need for increased clinical awareness of BED-associated medical complications and knowledge of full BED diagnostic criteria.