Changing the global obesity narrative to recognize and reduce weight stigma: A position statement from the World Obesity Federation

Weight stigma, defined as pervasive misconceptions and stereotypes associated with higher body weight, is both a social determinant of health and a human rights issue. It is imperative to consider how weight stigma may be impeding health promotion efforts on a global scale. The World Obesity Federation (WOF) convened a global working group of practitioners, researchers, policymakers, youth advocates, and individuals with lived experience of obesity to consider the ways that global obesity narratives may contribute to weight stigma. Specifically, the working group focused on how overall obesity narratives, food and physical activity narratives, and scientific and public-facing language may contribute to weight stigma. The impact of weight stigma across the lifespan was also considered. Taking a global perspective, nine recommendations resulted from this work for global health research and health promotion efforts that can help to reduce harmful obesity narratives, both inside and outside health contexts.

Weighty words: exploring terminology about weight among samples of physicians, obesity specialists, and the general public

BACKGROUND

The words used to refer to weight and individuals with large bodies can be used to reinforce weight stigma. Given that most previous research has examined preferred terminology within homogenous groups, this research sought to examine terminology preferences across populations.

METHODS

This paper reports on data gathered with the general public, family physicians, and obesity researchers/practitioners. Participants were asked about the words they commonly: (1) used to refer to people with large bodies (general public); (2) heard in their professional contexts (physicians and obesity specialists); and (3) perceived to be the most socially or professionally acceptable (all samples).

RESULTS

Similarities and differences were evident between samples, especially related to weight-related clinical terms, the word fat, and behavioral stereotypes.

CONCLUSION

The results provide some clarity into the differences between populations and highlight the need to incorporate use of strategies that may move beyond person-first language to humanize research and clinical practice with people with large bodies.

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.

A scoping review of obesity education interventions for current and prospective medical professionals in Canada

Background

Obesity is a prevalent chronic disease in Canada. Individuals living with obesity frequently interact with medical professionals who must be prepared to provide evidence-based and person-centred care options. The purpose of this scoping review was to summarize existing educational interventions on obesity in Canada for current and prospective medical professionals and to identify key future directions for practice and research.

Methods

A scoping review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews. The search strategy was conducted using Medline (via PubMed), Embase, Eric, CBCA, Proquest Education, and Proquest Theses. The inclusion criteria included delivery of an educational intervention on obesity for current medical professionals, medical undergraduate trainees, or residents administered in Canada. Data were extracted from the included studies to thematically summarize the intervention content, and main outcomes assessed. Future directions for research and practice were identified.

Results

Eight studies met the inclusion criteria. The interventions ranged in terms of the mode of delivery, including interactive in-person workshops and seminars, online learning modules, webinars, and videos. The main outcomes assessed were attitudes towards patients living with obesity, self-efficacy for having sensitive obesity-related discussions, skills to assess obesity and provision of management options. All studies reported improvements in the outcomes. Future directions identified were the need to develop standardized obesity competencies for inclusion across medical education programs, further research on effective pedagogical approaches to integrating content into existing curricula and the need for broader awareness and assessment of the quality of obesity education resources.

Conclusion

Although there have been few obesity-specific educational interventions for current and prospective medical professionals in Canada, existing evidence shows positive learning outcomes. These findings advocate for continued investment in the development of obesity medical training and educational interventions.

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

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

A scoping review of school-based anthropometric measurement

Though anthropometric measurement (AM) frequently occurs in school settings, it is not without risks to child wellbeing. The aim of this scoping review was to examine how AM in school settings takes place and is reported on to make recommendations on best practices. We identified and extracted data from 440 studies published since 2005 that conducted AM in school (pre-school through secondary/high school) settings. Privacy and sensitivity of AM were unclear in over 90% of studies. Thirty-one studies (7.0%) reported protecting student privacy, while nine (2.0%) reported public measurement. Only five studies reported sensitivity regarding AM (1.1%). Exactly who conducted AM was not specified in 201 studies (45.7%). Sixty-nine studies did not provide a weight status criteria citation (19.2%), and 10 used an incorrect citation (2.7%). In summary, serious shortcomings in the reporting of how AM is conducted and by whom, along with details concerning weight status classification, are evident. There is considerable room for improvement regarding the reporting of key methodological details. We propose best practices for AM in school settings, which also double as conditions that should be met before AM takes place in school settings.

Exploring body dissatisfaction in pregnancy and the association with gestational weight gain, obesity, and weight stigma

OBJECTIVE

Body dissatisfaction in pregnancy has been associated with negative psychological maternal outcomes, including increased risk of postpartum depression. This study aimed to explore weight-related factors that influence body dissatisfaction in pregnancy, including gestational weight gain (GWG), weight stigma, obesity, and weight loss attempts before pregnancy.

DESIGN

Secondary analysis of a larger cross-sectional study.

SETTING

Online survey administered via Qualtrics.

PARTICIPANTS

≥12 weeks pregnant, ≥18 years of age, having a singleton pregnancy and residing in Canada.

MEASUREMENTS AND FINDINGS

A battery of questionnaires were completed, including the Body Image in Pregnancy Scale (BIPS) sub-scale. The BIPS scores were compared based on experiences of weight stigma in pregnancy, perception towards their GWG, weight loss attempts before pregnancy, obesity, and GWG category classified as excessive or not referring to Institute of Medicine (2009) guidelines. Significant differences were entered into a linear regression model with BIPS scores as the dependent variable. Significance was accepted as p<0.05. A total of 182 participants completed the survey. There were no differences in BIPS scores based on GWG category (p = 0.160), or obesity (p = 0.230). Poorer BIPS scores were reported by those who felt they had gained 'too much' pregnancy weight than 'appropriate' (p<0.001), and among those who were trying to lose weight before pregnancy compared to those who were not (p = 0.002). Poorer BIPS scores were also reported by individuals who indicated they had experienced weight stigma during pregnancy compared to those who had not (p<0.001). Regression results showed that significant variables were perceptions towards GWG (p = 0.003) and experiencing weight stigma in pregnancy (p = 0.011).

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Perceptions towards GWG and experiencing weight stigma can influence body dissatisfaction in pregnancy. Given the detrimental physical and psychological consequences of body dissatisfaction, effective strategies to reduce prenatal weight stigma are needed, such as training maternal healthcare providers to offer sensitive preconception and prenatal weight counselling.

Exploring weight bias internalization in pregnancy

Background

Recent research has shown that pregnant individuals experience weight stigma throughout gestation, including negative comments and judgement associated with gestational weight gain (GWG). Weight bias internalization (WBI) is often a result of exposure to weight stigma and is detrimental to biopsychological health outcomes. The purpose of this study was to explore WBI in pregnancy and compare scores based on maternal weight-related factors including pre-pregnancy body mass index (BMI), obesity diagnosis and excessive GWG.

Methods

Pregnant individuals in Canada and USA completed a modified version of the Adult Weight Bias Internalization Scale. Self-reported pre-pregnancy height and weight were collected to calculate and classify pre-pregnancy BMI. Current weight was also reported to calculate GWG, which was then classified as excessive or not based on Institute of Medicine (2009) guidelines. Participants indicated if they were diagnosed with obesity by a healthcare provider. Inferential analyses were performed comparing WBI scores according to pre-pregnancy BMI, excessive GWG, and obesity diagnosis. Significance was accepted as p < 0.05 and effect sizes accompanied all analyses.

Result

336 pregnant individuals completed the survey, with an average WBI score of 3.9 ± 1.2. WBI was higher among those who had a pre-pregnancy BMI of obese than normal weight (p = 0.04, η² = 0.03), diagnosed with obesity than not diagnosed (p < 0.001, Cohen’s d = 1.3), and gained excessively versus not (p < 0.001, Cohen’s d = 1.2).

Conclusions

Pregnant individuals who have a higher BMI, obesity and gain excessively may experience WBI. Given that weight stigma frequently occurs in pregnancy, effective person-oriented strategies are needed to mitigate stigma and prevent and care for WBI.

Examining the Conceptual and Measurement Overlap of Body Dissatisfaction and Internalized Weight Stigma in Predominantly Female Samples: A Meta-Analysis and Measurement Refinement Study

Both body dissatisfaction and internalized weight stigma have been identified as risk factors for many negative health outcomes for women, including depression and eating disorders. In addition to these contributions, these concepts have been found to overlap to various degrees in existing literature. We conducted a systematic review and meta-analysis on articles published prior to February 2022 to demonstrate the conceptual and measurement overlap between body dissatisfaction and internalized weight stigma as currently quantified. We identified 48 studies examining the interrelation between body dissatisfaction and internalized weight stigma in predominantly female samples. Stronger correlations between these two constructs, some bordering on multicollinearity, were prevalent in community samples compared to clinical samples and with some but not all the commonly used measures in the body image and weight stigma fields. Body mass index (BMI) moderated these relations such that individuals with higher self-reported BMI were more likely to report lower correlations between the constructs. This concept proliferation, stronger for individuals with lower BMIs and community samples, necessitates the need change how we conceptualize and measure body dissatisfaction and internalized weight stigma. To this end, we conducted study two to refine existing measures and lessen the degree of measurement overlap between internalized weight stigma and body dissatisfaction, particularly in community samples of women. We aimed to clarify the boundaries between these two concepts, ensuring measurement error is better accounted for. Female university students completed existing measures of body satisfaction and internalized weight stigma, which were analyzed using an exploratory followed by a confirmatory factor analysis. In our attempts to modify two existing measures of internalized weight stigma and body dissatisfaction, the majority of the internalized weight stigma items were retained. In contrast, most of the body dissatisfaction items either cross-loaded onto both factors or loaded on to the internalized weight stigma factor despite being intended for the body dissatisfaction factor, suggesting that the measurement issues identified in recent prior research may be due not only to the way we conceptualize and quantify weight stigma, but also the ways in which we quantify body dissatisfaction, across the existing corpus of body dissatisfaction scales.

Towards a sociocultural model of weight stigma

PURPOSE

Weight stigma is pervasive and is associated with numerous physical and psychological health consequences, including decreased body satisfaction. Understanding of contributing factors to weight stigma remains limited, although researchers have consistently documented the connection between weight controllability beliefs and weight stigma. Sociocultural factors, including thin-ideal internalization and related social-cognitive correlates, are in the nascent stages of exploration to further our understanding of weight stigma.

METHODS

In this study, we tested an emerging sociocultural model of weight stigma, examining the influence of thin-ideal internalization and appearance-related comparisons on weight stigma, statistically controlling for weight controllability beliefs and accounting for thin-ideal environmental influences. Participants were 137 MTurk workers living in the United States.

RESULTS

We found that increased thin-ideal information was associated with thin-ideal internalization, which in turn was related to both upward and downward appearance-related comparison tendencies. These comparisons were then significantly related to weight stigma, controlling for weight controllability beliefs. There were significant indirect effects of both upward and downward appearance-related comparison tendencies on the relation between thin-ideal internalization and weight stigma.

CONCLUSION

These results extend limited prior research examining the association between the thin-ideal and appearance-related comparisons with weight stigma, and contribute to a more nuanced understanding of this complex phenomenon.

LEVEL OF EVIDENCE

Level V, cross-sectional study.

The Efficacy of Comprehensive School Health Course in Changing Pre-Service Teachers’ Attitudes and Reactions Toward Weight-Related Teasing

Teachers view overt expressions of weight stigma, such as weight-related teasing, as troublesome but are often ill-prepared to address instances of weight-related teasing when they arise in the classroom. Comprehensive school health is an emerging framework that aims to better prepare teachers to address issues of health and wellness in the classroom, including weight-related teasing. We examined the efficacy of a university course in comprehensive school health in changing pre-service teachers’ attitudes and perceptions of weight-related teasing. Pre-service teachers read a vignette and responded to 10 items about the vignette at both the beginning and end of the semester-long course. Items relating to pre-service teachers’ perception of, responsibility and obligation to address the weight-related teasing event showed significant, positive change from the beginning to end of the semester. These results suggest that exposure to developmentally sound methods of delivering health-related content can support adaptive educator reactions to weight-related teasing.

Weight Bias in Educational Settings: a Systematic Review

PURPOSE

To conduct a systematic literature review of empirical peer-reviewed published studies on the prevalence of weight bias among students, pre-service, and in-service teachers and its impact on the educational experiences and health of students from kindergarten to postsecondary settings.

METHODS

Keywords were searched on three main concepts, (i) weight bias/stigma, (ii) obesity/overweight, and (iii) education, within eight databases. Our search yielded 8323 individual records, of which 45 studies satisfied our inclusion criteria.

RESULTS

Most studies were conducted in K-12 school settings (n = 41), were quantitative in design (n = 37), and used student samples (n = 18). Weight bias is prevalent in educational settings, among peers at school as well as pre-service and in-service teachers, and negatively impacts students' health and educational experiences.

CONCLUSION

These results highlighted the impact of weight bias in creating inequity for students with obesity as well as several underexamined areas, such as weight bias in postsecondary settings and attitudes among teachers and pre-service teachers. Innovative strategies to address weight bias in educational settings are needed.

Examining Weight Bias among Practicing Canadian Family Physicians

OBJECTIVES

The aim of this study was to examine the attitudes of practicing Canadian family physicians about individuals with obesity, their healthcare treatment, and perceptions of obesity treatment in the public healthcare system.

METHOD

A national sample of Canadian practicing family physicians (n = 400) completed the survey. Participants completed measures of explicit weight bias, attitudes towards treating patients with obesity, and perceptions that people with obesity increase demand on the public healthcare system.

RESULTS

Responses consistent with weight bias were not observed overall but were demonstrated in a sizeable minority of respondents. Many physicians also reported feeling frustrated with patients with obesity and agreed that people with obesity increase demand on the public healthcare system. Male physicians had more negative attitudes than females. More negative attitudes towards treating patients with obesity were associated with greater perceptions of them as a public health demand.

CONCLUSION

Results suggest that negative attitudes towards patients with obesity exist among some family physicians in Canada. It remains to be determined if physicians develop weight bias partly because they blame individuals for their obesity and its increased demand on the Canadian public healthcare system. More research is needed to better understand causes and consequences of weight bias among health professionals and make efforts towards its reduction in healthcare.

Weight bias reduction in health professionals: a systematic review

Innovative and coordinated strategies to address weight bias among health professionals are urgently needed. We conducted a systematic literature review of empirical peer-reviewed published studies to assess the impact of interventions designed to reduce weight bias in students or professionals in a health-related field. Combination sets of keywords based on three themes (1: weight bias/stigma; 2: obesity/overweight; 3: health professional) were searched within nine databases. Our search yielded 1447 individual records, of which 17 intervention studies satisfied the inclusion criteria. Most studies (n = 15) included medical, dietetic, health promotion, psychology and kinesiology students, while the minority included practicing health professionals (n = 2). Studies utilized various bias-reduction strategies. Many studies had methodological weaknesses, including short assessment periods, lack of randomization, lack of control group and small sample sizes. Although many studies reported changes in health professionals' beliefs and knowledge about obesity aetiology, evidence of effectiveness is poor, and long-term effects of intervention strategies on weight bias reduction remain unknown. The findings highlight the lack of experimental research to reduce weight bias among health professionals. Although changes in practice will likely require multiple strategies in various sectors, well-designed trials are needed to test the impact of interventions to decrease weight bias in healthcare settings.

Positioning of Weight Bias: Moving towards Social Justice

Weight bias is a form of stigma with detrimental effects on the health and wellness of individuals with large bodies. Researchers from various disciplines have recognized weight bias as an important topic for public health and for professional practice. To date, researchers from various areas have approached weight bias from independent perspectives and from differing theoretical orientations. In this paper, we examined the similarities and differences between three perspectives (i.e., weight-centric, non-weight-centric (health-centric), and health at every size) used to understand weight bias and approach weight bias research with regard to (a) language about people with large bodies, (b) theoretical position, (c) identified consequences of weight bias, and (d) identified influences on weight-based social inequity. We suggest that, despite differences, each perspective acknowledges the negative influences that position weight as being within individual control and the negative consequences of weight bias. We call for recognition and discussion of weight bias as a social justice issue in order to change the discourse and professional practices extended towards individuals with large bodies. We advocate for an emphasis on social justice as a uniting framework for interdisciplinary research on weight bias.

New measurement of the cosmic-ray positron fraction from 5 to 15 GeV

We present a new measurement of the cosmic-ray positron fraction at energies between 5 and 15 GeV with the balloon-borne HEAT-pbar instrument in the spring of 2000. The data presented here are compatible with our previous measurements, obtained with a different instrument. The combined data from the three HEAT flights indicate a small positron flux of nonstandard origin above 5 GeV. We compare the new measurement with earlier data obtained with the HEAT-e(+/-) instrument, during the opposite epoch of the solar cycle, and conclude that our measurements do not support predictions of charge sign dependent solar modulation of the positron abundance at 5 GeV.

Measurement of the cosmic-ray antiproton-to-proton abundance ratio between 4 and 50 GeV

We present a new measurement of the antiproton-to-proton abundance ratio, pbar/p, in the cosmic radiation. The HEAT-pbar instrument, a balloon borne magnet spectrometer with precise rigidity and multiple energy loss measurement capability, was flown successfully in Spring 2000, at an average atmospheric depth of 7.2 g/cm(2). A total of 71 antiprotons were identified above the vertical geomagnetic cutoff rigidity of 4.2 GV. The highest measured proton energy was 81 GeV. We find that the pbar/p abundance ratio agrees with that expected from a purely secondary origin of antiprotons produced by primary protons with a standard soft energy spectrum.

Colonic bacterial activity, biliary cholesterol saturation, and pathogenesis of gallstones

The relation between colonic bacterial metabolites in bile and saturation of bile with cholesterol was investigated. Eleven healthy men ingested metronidazole (2 g daily) for 10 days to inhibit anaerobic bacterial activity. Bile composition was determined in fasting samples aspirated from the duodenum before metronidazole was given, at the end of 10 days on metronidazole, and a month after the drug was discontinued. Bile cholesterol saturation fell in ten of the eleven subjects from a mean of 1.00 to 0.83 and rose in all eleven after the drug was stopped. At the same time the proportion of deoxycholate in bile acid decreased from a mean of 24% to 7%, returning to 22% of the total a month after metronidazole had been stopped, and the proportion of chenodeoxycholate changed significantly from 33% to 46% and back to 33%. There was little change in cholate concentrations. Deoxycholate is formed exclusively by bacterial action in the colon. Its administration increases cholesterol saturation of bile, while chenodeoxycholate reduces it. These results suggest that colonic function is important in regulating bile composition. Dietary measures which reduce the return of newly formed deoxycholate from the colon to the bile reduce cholesterol saturation and so are likely to reduce the risk of gallstones.

Xylose test: effect of aspirin and indomethacin

The xylose test was used to assess the effect of drugs on intestinal absorption. Both aspirin and indomethacin reduced the urinary output of xylose. By giving xylose intravenously as well as orally it was found that aspirin had a parenteral effect, probably impairing renal function, whereas indomethacin depressed intestinal absorption.

The influence of sex, body weight, and renal function on the xylose test

A low excretion of xylose may be due to malabsorption, renal disease, or old age. Malabsorption can be distinguished from other causes by performing a combined oral and intravenous test, the result being expressed as a fraction of these readings. Sex and body weight do not influence the xylose test.