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Potential unintended consequences of graphic warning labels on sugary drinks: do they promote obesity stigma?
Hayward, LE, Vartanian, LR
Obesity science & practice. 2019;5(4):333-341
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Consumption of sugar-sweetened beverages is associated with increased body weight and poor nutrition and health outcomes, including Type 2 diabetes and coronary heart disease. The aim of this study was to test the hypothesis that the graphic warning promotes weight bias (Study 1) and is also viewed as stigmatizing by people with overweight and obesity (Study 2). Study 1 Participants were randomly allocated to one of two conditions: a warning label condition (n = 324) or a control condition (n = 357). Results indicate that participants who were presented with the graphic warning label were more likely to intend to purchase water (instead of the soda) than participants who were presented with the standard label. Study 2 Participants (n=561) were randomly assigned to one of two conditions – overweight or obese. Results show that the majority of participants rated the warning label as personally stigmatizing. Moreover, after being exposed to the label, the participants experienced worse mood. Authors conclude that it is important for policymakers to strike a balance between the benefits and costs of public health interventions.
Abstract
INTRODUCTION Public health interventions need to balance the benefits with any potential harms. One proposed intervention for reducing sugar-sweetened beverage consumption involves placing graphic warning labels on products and advertisements. A recent study found that a graphic warning label that contained negative imagery of obesity reduced purchases of sugar-sweetened beverages. However, these labels may also promote obesity stigma, which is concerning given that weight stigma is associated with harmful health consequences including weight gain and increased risk of mortality. METHODS In Study 1 (n = 681), participants viewed a standard soda label or the graphic warning label online and then completed measures of disgust and prejudice towards people with obesity. In Study 2 (n = 506), participants who identified as having overweight or obesity viewed the graphic warning label online before or after completing measures of mood and state self-esteem. RESULTS In Study 1, participants who had viewed the graphic warning label reported higher disgust and weight bias. In Study 2, the majority of participants perceived the warning label to be stigmatizing, and participants displayed worse mood and, through this, lower self-esteem after viewing the label. CONCLUSIONS Although the graphic warning label has been found to reduce sugary drink purchases, it also promotes obesity stigma and is perceived as stigmatizing by individuals with overweight and obesity. Given that weight stigma predicts harmful health and well-being consequences, the benefits of graphic warning labels need to be balanced against the potential costs.
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Examining Weight Bias among Practicing Canadian Family Physicians.
Alberga, AS, Nutter, S, MacInnis, C, Ellard, JH, Russell-Mayhew, S
Obesity facts. 2019;12(6):632-638
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Weight bias represents negative attitudes and beliefs about individuals because of their weight. The aim of this study was to examine: a. weight bias in a national sample of family physicians in Canada, b. the relationships between weight bias, attitudes about treating patients with obesity, and how people with obesity are perceived as a burden to the public healthcare system. A probability sample of 400 currently practicing family physicians completed the survey by phone or online. Results show that most respondents were white (63.3%) men (61.3%) aged 45 years or older. The average total score of explicit weight bias was 2.95 (1.17) evaluated on a 7-point Likert scale. Furthermore, although weight bias was not present in the majority of the sample, it was present among some physicians. Authors conclude that future work is needed to investigate weight bias reduction techniques targeted at physicians.
Abstract
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.
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How and why weight stigma drives the obesity 'epidemic' and harms health.
Tomiyama, AJ, Carr, D, Granberg, EM, Major, B, Robinson, E, Sutin, AR, Brewis, A
BMC medicine. 2018;16(1):123
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Weight stigma is defined as the social rejection and devaluation that accrues to those who do not comply with prevailing social norms of adequate body weight and shape. In this opinion-based study, authors discuss that: • Latest literature indicates that weight stigma can trigger physiological and behavioural changes linked to poor metabolic health and increased weight gain. • Healthcare is a setting in which weight stigma is particularly pervasive, with significant consequences for the health of higher-weight patients. This stigma has direct and observable consequences for the quality and nature of services provided to those with obesity. • Stigma may be an unintended consequence of anti-obesity efforts, undermining their intended effect. Moreover, focusing solely on obesity treatment runs the risk of missing other diagnoses. • The science of weight stigma crystallizes a key point for future success – to tackle the obesity ‘epidemic’ we must tackle the parallel epidemic of weight stigma. • Public service messages are needed to educate people about the stigma, discrimination, and challenges facing higher-weight individuals. Authors conclude that to advance as an equal society, healthcare providers should lead the way for weight stigma eradication.
Abstract
BACKGROUND In an era when obesity prevalence is high throughout much of the world, there is a correspondingly pervasive and strong culture of weight stigma. For example, representative studies show that some forms of weight discrimination are more prevalent even than discrimination based on race or ethnicity. DISCUSSION In this Opinion article, we review compelling evidence that weight stigma is harmful to health, over and above objective body mass index. Weight stigma is prospectively related to heightened mortality and other chronic diseases and conditions. Most ironically, it actually begets heightened risk of obesity through multiple obesogenic pathways. Weight stigma is particularly prevalent and detrimental in healthcare settings, with documented high levels of 'anti-fat' bias in healthcare providers, patients with obesity receiving poorer care and having worse outcomes, and medical students with obesity reporting high levels of alcohol and substance use to cope with internalized weight stigma. In terms of solutions, the most effective and ethical approaches should be aimed at changing the behaviors and attitudes of those who stigmatize, rather than towards the targets of weight stigma. Medical training must address weight bias, training healthcare professionals about how it is perpetuated and on its potentially harmful effects on their patients. CONCLUSION Weight stigma is likely to drive weight gain and poor health and thus should be eradicated. This effort can begin by training compassionate and knowledgeable healthcare providers who will deliver better care and ultimately lessen the negative effects of weight stigma.
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Predictors of weight stigma experienced by middle-older aged, general-practice patients with obesity in disadvantaged areas of Australia: a cross-sectional study.
Spooner, C, Jayasinghe, UW, Faruqi, N, Stocks, N, Harris, MF
BMC public health. 2018;18(1):640
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People in higher categories of obesity are at substantially increased health risk because mortality increases sharply as body mass index rises above 30. In addition to physical health risks, people with obesity commonly experience weight-related stigma. The aim of this study was to identify predictors of perceived weight stigma among patients with obesity attending general practices in socioeconomically disadvantaged urban areas of Australia. This is a cross-sectional study for which data from telephone interviews with patients with obesity were used. Patients were recruited from 17 general practices in socioeconomically disadvantaged areas of Sydney and Adelaide. Results indicate that one-third of the sample had experienced direct forms of weight discrimination in the week before being interviewed. Furthermore, weight discrimination was more likely to be experienced by patients in higher obesity categories, who were not employed, who spoke a language other than English at home and who had lower scores on the Health Literacy Questionnaire domain (that measures the ability to actively engage with healthcare providers). Authors conclude that weight stigma may compound other forms of social disadvantage. Thus, strategies are needed to address weight stigma at the individual, system and population levels and to educate primary care providers to be more alert to the needs of their patients with obesity.
Abstract
BACKGROUND Rates of obesity have increased globally and weight stigma is commonly experienced by people with obesity. Feeling stigmatised because of one's weight can be a barrier to healthy eating, physical activity and to seeking help for weight management. The aim of this study was to identify predictors of perceived weight among middle-older aged patients with obesity attending general practices in socioeconomically disadvantaged urban areas of Australia. METHODS As part of a randomised clinical trial in Australia, telephone interviews were conducted with 120 patients from 17 general practices in socioeconomically disadvantaged of Sydney and Adelaide. Patients were aged 40-70 years with a BMI ≥ 30 kg/m2. The interviews included questions relating to socio-demographic variables (e.g. gender, language spoken at home), experiences of weight-related discrimination, and the Health Literacy Questionnaire (HLQ). Multi-level logistic regression data analysis was undertaken to examine predictors of recent experiences of weight-related discrimination ("weight stigma"). RESULTS The multi-level model showed that weight stigma was positively associated with obesity category 2 (BMI = 35 to < 40; OR 4.47 (95% CI 1.03 to 19.40)) and obesity category 3 (BMI = ≥ 40; OR 27.06 (95% CI 4.85 to 150.95)), not being employed (OR 7.70 (95% CI 2.17 to 27.25)), non-English speaking backgrounds (OR 5.74 (95% CI 1.35 to 24.45)) and negatively associated with the HLQ domain: ability to actively engage with healthcare providers (OR 0.12 (95% CI 0.05 to 0.28)). There was no association between weight stigma and gender, age, education or the other HLQ domains examined. CONCLUSIONS Weight stigma disproportionately affected the patients with obesity most in need of support to manage their weight: those with more severe obesity, from non-English speaking backgrounds and who were not in employment. Additionally, those who had experienced weight stigma were less able to actively engage with healthcare providers further compounding their disadvantage. This suggests the need for a more proactive approach to identify weight stigma by healthcare providers. Addressing weight stigma at the individual, system and population levels is recommended. TRIAL REGISTRATION The trial was registered with the Australian Clinical Trials Registry ACTRN126400102162 .
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Comparing Self-Report Measures of Internalized Weight Stigma: The Weight Self-Stigma Questionnaire versus the Weight Bias Internalization Scale.
Hübner, C, Schmidt, R, Selle, J, Köhler, H, Müller, A, de Zwaan, M, Hilbert, A
PloS one. 2016;11(10):e0165566
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Individuals with overweight and obesity are exposed to weight stigmatization in many domains of life, for example, in employment, in educational and health care settings, in the media as well as in interpersonal relationships. The aim of this study was to compare the psychometric properties and predictive values for health outcomes of two different self-report questionnaires (the Weight Self-Stigma Questionnaire and the Weight Bias Internalization Scale). This study was part of a larger project that investigated the impact of body contouring surgery after bariatric surgery on psychosocial aspects. It is a cross-sectional study which included all data of a subsample consisting of N = 78 patients prior bariatric surgery. Results indicate that both measures did not differ with respect to overall convergent validity and predictive values for multiple psychosocial health outcomes. Findings also showed that the Weight Bias Internalization Scale has better internal consistency compared to the Weight Self-Stigma Questionnaire. Authors suggest that clinical practice and research might give preference to the Weight Bias Internalization Scale in bariatric surgery samples because of the marginally better reliability, convergent validity, and greater predictive power.
Abstract
BACKGROUND Internalized weight stigma has gained growing interest due to its association with multiple health impairments in individuals with obesity. Especially high internalized weight stigma is reported by individuals undergoing bariatric surgery. For assessing this concept, two different self-report questionnaires are available, but have never been compared: the Weight Self-Stigma Questionnaire (WSSQ) and the Weight Bias Internalization Scale (WBIS). The purpose of the present study was to provide and to compare reliability, convergent validity with and predictive values for psychosocial health outcomes for the WSSQ and WBIS. METHODS The WSSQ and the WBIS were used to assess internalized weight stigma in N = 78 prebariatric surgery patients. Further, body mass index (BMI) was assessed and body image, quality of life, self-esteem, depression, and anxiety were measured by well-established self-report questionnaires. Reliability, correlation, and regression analyses were conducted. RESULTS Internal consistency of the WSSQ was acceptable, while good internal consistency was found for the WBIS. Both measures were significantly correlated with each other and body image. While only the WSSQ was correlated with overweight preoccupation, only the WBIS was correlated with appearance evaluation. Both measures were not associated with BMI. However, correlation coefficients did not differ between the WSSQ and the WBIS for all associations with validity measures. Further, both measures significantly predicted quality of life, self-esteem, depression, and anxiety, while the WBIS explained significantly more variance than the WSSQ total score for self-esteem. CONCLUSIONS Findings indicate the WSSQ and the WBIS to be reliable and valid assessments of internalized weight stigma in prebariatric surgery patients, although the WBIS showed marginally more favorable results than the WSSQ. For both measures, longitudinal studies on stability and predictive validity are warranted, for example, for weight-related and psychosocial outcomes.
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Obese children, adults and senior citizens in the eyes of the general public: results of a representative study on stigma and causation of obesity.
Sikorski, C, Luppa, M, Brähler, E, König, HH, Riedel-Heller, SG
PloS one. 2012;7(10):e46924
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Obesity is a major health problem and associated with higher mortality and worse health outcomes. Obese individuals are commonly blamed for their excess weight which may lead to stigmatisation and discrimination which can further exacerbate unhealthy eating and activity behaviour, cause psychological problems, and prevent them from seeking help and health care. The aim of this telephone interview study of 3,003 persons was to investigate the prevalence of stigmatizing attitudes and determining the causal attribution of obesity by the German general public. Assessment of attitudes was through vignettes, i.e. presenting participants with a brief description of an obese or normal weight person, followed by vignette specific questions. The average Fat Phobia Score (FPS), which assesses stigmatising attitudes on a scale of 1 (positive attitude) to 5 (negative attitude), was 3.65 for obese vignettes compared to 2.38 for normal weight vignettes, indicating a negative attitude towards obesity, which was stronger towards obese children than towards obese adults or elderly. Causal attribution was significantly stronger for internal factors (lack of activity, eating too much, lack of willpower), whilst external and genetic factors were rated similar. For children genetic causes were agreed on less whilst external factors were seen as more important for a child’s obesity. Participants who favoured internal factors were also more likely to have a more negative view of obesity. Participants with a higher level of education or who were themselves overweight/obese or had an overweight/obese partner had a more positive attitude towards obesity.
Abstract
Obese individuals are blamed for their excess weight based on causal attribution to the individual. It is unclear whether obese individuals of different age groups and gender are faced with the same amount of stigmatization. This information is important in order to identify groups of individuals at risk for higher stigmatization and discrimination. A telephone interview was conducted in a representative sample of 3,003 participants. Experimental manipulation was realized by vignettes describing obese and normal-weight children, adults and senior citizens. Stigmatizing attitudes were measured by semantic differential. Causal attribution was assessed. Internal factors were rated with highest agreement rates as a cause for the vignette's obesity. Lack of activity behavior and eating too much are the most supported causes. Importance of causes differed for the different vignettes. For the child, external causes were considered more important. The overweight vignette was rated consistently more negatively. Higher educational attainment and personal obesity were associated with lower stigmatizing attitudes. The vignette of the obese child was rated more negatively compared to that of an adult or senior citizen. Obesity is seen as a controllable condition, but for children external factors are seen as well. Despite this finding, they are faced with higher stigmatizing attitudes in the general public, contradicting attribution theory assumptions. Internal and external attribution were found to be inter-correlated. Obese children are the population most at risk for being confronted with stigmatization, making them a target point in stigma-reduction campaigns.
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The stigma of obesity in the general public and its implications for public health - a systematic review.
Sikorski, C, Luppa, M, Kaiser, M, Glaesmer, H, Schomerus, G, König, HH, Riedel-Heller, SG
BMC public health. 2011;11:661
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Obesity rates are still rising and, in addition to co-morbid diseases, perceived discrimination and stigmatisation leads to worse outcomes in obese individuals. The aim of this systematic review, including seven studies, was to investigate how the lay public perceive people with obesity or overweight (stigmatizing attitudes); (b) what they attribute obesity to (causal attribution) and (c) what types of interventions they support. Higher rates of stigmatising attitudes were associated with attributing obesity more to behaviour and less to heredity, lower levels of education and older age of the respondents, and not seeing obesity as an illness. Causal attributions varied slightly from study to study but most found that lack of activity behaviour, overeating and lack of willpower were the most prevalent causal attributions, with more than two thirds of respondents associating these factors to obesity, whilst only about a third agreed to heredity being an important factor. Environmental factors, in particular a bad food environment, was seen as a possible factor in obesity by about half of the respondents. In terms of prevention efforts, support was highest for childhood prevention and information campaigns, followed by banning junk foods in schools and banning junk food advertising, whilst taxation of unhealthy foods received the least support.
Abstract
BACKGROUND Up to this date, prevalence rates of obesity are still rising. Aside from co-morbid diseases, perceived discrimination and stigmatization leads to worsen outcomes in obese individuals. Higher stigmatizing attitudes towards obese individuals may also result in less support of preventive and interventive measures. In light of the immense burden of obesity on health care systems and also on the individuals' quality of life, accepted and subsidized preventive measures are needed. Policy support might be determined by views of the lay public on causes of obesity and resulting weight stigma. This study seeks to answer how representative samples of the lay public perceive people with obesity or overweight status (stigmatizing attitudes); what these samples attribute obesity to (causal attribution) and what types of interventions are supported by the lay public and which factors determine that support (prevention support). METHODS A systematic literature search was conducted. All studies of representative samples reporting results on (a) stigmatizing attitudes towards overweight and obese individuals, (b) causal beliefs and (c) prevention support were included. RESULTS Only 7 articles were found. One study reported prevalence rates of stigmatizing attitudes. About a quarter of the population in Germany displayed definite stigmatizing attitudes. Other studies reported causal attributions. While external influences on weight are considered as well, it seems that internal factors are rated to be of higher importance. Across the studies found, regulative prevention is supported by about half of the population, while childhood prevention has highest approval rates. Results on sociodemographic determinants differ substantially. CONCLUSIONS Further research on public attitudes toward and perception of overweight and obesity is urgently needed to depict the prevailing degree of stigmatization. Introducing a multidimensional concept of the etiology of obesity to the lay public might be a starting point in stigma reduction.
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Perceptions of weight discrimination: prevalence and comparison to race and gender discrimination in America.
Puhl, RM, Andreyeva, T, Brownell, KD
International journal of obesity (2005). 2008;32(6):992-1000
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Overweight individuals are frequent targets of weight stigmatisation and prejudice. Negative implications include impairments in psychological well-being and physical health. The aim of this study was to document rates and patterns of weight/height discrimination in comparison to other forms of discrimination (based on gender and race) among adults in the United States. Respondents were drawn from a nationally representative sample of community-based English-speaking adults aged 25–74 years in the United States. A total of 2290 individuals (1104 men and 1186 women) were eligible for the study. Results demonstrate greater vulnerability to weight bias among youth at higher levels of obesity, and that women are more vulnerable to weight/height discrimination than men. Authors conclude that the prevalence of weight/height discrimination is high in the United States and it is comparable to rates of racial discrimination.
Abstract
OBJECTIVE Limited data are available on the prevalence and patterns of body weight discrimination from representative samples. This study examined experiences of weight/height discrimination in a nationally representative sample of US adults and compared their prevalence and patterns with discrimination experiences based on race and gender. METHOD AND PROCEDURES Data were from the National Survey of Midlife Development in the United States, a 1995-1996 community-based survey of English-speaking adults aged 25-74 (N=2290). Reported experiences of weight/height discrimination included a variety of institutional settings and interpersonal relationships. Multivariate regression analyses were used to predict weight/height discrimination controlling for sociodemographic characteristics and body weight status. RESULTS The prevalence of weight/height discrimination ranged from 5% among men to 10% among women, but these average percentages obscure the much higher risk of weight discrimination among heavier individuals (40% for adults with body mass index (BMI) of 35 and above). Younger individuals with a higher BMI had a particularly high risk of weight/height discrimination regardless of their race, education and weight status. Women were at greater risk for weight/height discrimination than men, especially women with a BMI of 30-35 who were three times more likely to report weight/height discrimination compared to male peers of a similar weight. DISCUSSION Weight/height discrimination is prevalent in American society and is relatively close to reported rates of racial discrimination, particularly among women. Both institutional forms of weight/height discrimination (for example, in employment settings) and interpersonal mistreatment due to weight/height (for example, being called names) were common, and in some cases were even more prevalent than discrimination due to gender and race.
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Being 'fat' in today's world: a qualitative study of the lived experiences of people with obesity in Australia.
Thomas, SL, Hyde, J, Karunaratne, A, Herbert, D, Komesaroff, PA
Health expectations : an international journal of public participation in health care and health policy. 2008;11(4):321-30
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The obesity epidemic is one of the most pressing contemporary public health problems. The aim of this study was to develop a picture of both lived experiences of obesity and the impact of socio-cultural factors on obesity. The study adopted a qualitative research design (n=76) . A broad interview schedule was developed by the authors aimed at individuals from a broad range of backgrounds and experiences of obesity. Results indicate that: (a) the experiences of obesity are diverse but there are common themes. (b) people living with obesity have heard the messages but find it difficult to act upon them. (c) interventions should be tailored to address both individual and community needs. (d) there should be a different approach towards obesity interventions. Authors conclude that interventions should respond directly to the social and cultural dimensions of communities and clusters of individuals.
Abstract
OBJECTIVE To develop an in-depth picture of both lived experience of obesity and the impact of socio-cultural factors on people living with obesity. DESIGN Qualitative methodology, utilizing in-depth semi-structured interviews with a community sample of obese adults (body mass index >or=30). Community sampling methods were supplemented with purposive sampling techniques to ensure a diverse range of individuals were included. RESULTS Seventy-six individuals (aged 16-72) were interviewed. Most had struggled with their weight for most of their lives (n=45). Almost all had experienced stigma and discrimination in childhood (n=36), as adolescents (n=41) or as adults (n=72). About half stated that they had been humiliated by health professionals because of their weight. Participants felt an individual responsibility to lose weight, and many tried extreme forms of dieting to do so. Participants described an increasing culture of 'blame' against people living with obesity perpetuated by media and public health messages. Eighty percent said that they hated or disliked the word obesity and would rather be called fat or overweight. DISCUSSION AND CONCLUSION There are four key conclusions: (i) the experiences of obesity are diverse, but there are common themes, (ii) people living with obesity have heard the messages but find it difficult to act upon them, (iii) interventions should be tailored to address both individual and community needs and (iv) we need to rethink how to approach obesity interventions to ensure that avoid recapitulating damaging social stereotypes and exacerbating social inequalities.