Bringing an end to diabetes stigma and discrimination: an international consensus statement on evidence and recommendations.

People with diabetes often encounter stigma (ie, negative social judgments, stereotypes, prejudice), which can adversely affect emotional, mental, and physical health; self-care, access to optimal health care; and social and professional opportunities. To accelerate an end to diabetes stigma and discrimination, an international multidisciplinary expert panel (n=51 members, from 18 countries) conducted rapid reviews and participated in a three-round Delphi survey process. We achieved consensus on 25 statements of evidence and 24 statements of recommendations. The consensus is that diabetes stigma is driven primarily by blame, perceptions of burden or sickness, invisibility, and fear or disgust. On average, four in five adults with diabetes experience diabetes stigma and one in five experience discrimination (ie, unfair and prejudicial treatment) due to diabetes, such as in health care, education, and employment. Diabetes stigma and discrimination are harmful, unacceptable, unethical, and counterproductive. Collective leadership is needed to proactively challenge, and bring an end to, diabetes stigma and discrimination. Consequently, we achieved unanimous consensus on a pledge to end diabetes stigma and discrimination.

Prevalence of diagnosed psychiatric disorders among adults who have experienced and internalized weight stigma.

Objective: Experiences and internalization of weight stigma are associated with greater self-reported psychological distress and symptoms of psychiatric disorders such as depression and anxiety. However, little is known about the extent to which individuals who have experienced and internalized weight stigma are diagnosed with or provided treatment for psychiatric conditions. The current study aimed to characterize the prevalence of diagnosed psychiatric disorders among adults with obesity who had experienced and internalized weight stigma. Methods: Weight-loss treatment-seeking adults with a history of experiencing weight stigma and high levels of internalized weight stigma were recruited for two clinical trials. Results: In Study 1 (n = 84, 83.3% women, 67.9% Black), 25% of participants reported a lifetime history of a mood disorder. Few participants (<10%) reported current psychiatric diagnoses or use of psychiatric medications. In Study 2 (n = 129, 88.4% women, 65.1% white), one-third of participants reported a mood disorder history, and 21.7% reported an anxiety disorder history, with approximately 16%-18% reporting current diagnoses. In both studies, few participants reported a history of a diagnosed eating disorder despite high rates of current full- or subthreshold symptoms. Based on Beck Depression Inventory-II scores, approximately 54%-64% of participants reported mild or greater symptoms of depression. Conclusions: Overall, lifetime history of diagnosed psychiatric disorders and current symptoms of depression and eating disorders were relatively high across two samples. More research is needed to determine the impact of weight stigma on the diagnosis and treatment of eating disorders and other psychiatric concerns.

Comparing measurement of internalized weight stigma and body dissatisfaction.

Respective conceptualizations of internalized weight stigma and body dissatisfaction are distinct; however, strong relationships between measures of these two constructs prompts consideration about if these are truly unique constructs or whether current measurement tools are not adequately capturing their uniqueness. In this cross-sectional study, 480 U.S. women (78.8% white; MBMI = 25.9) ages 18-40 years, recruited from Amazon's MechanicalTurk and a mid-sized university, completed an online survey with the Modified Weight Bias Internalization Scale (WBIS-M), a modified Body Parts Satisfaction Scale (BPSS), and other validated measures of body image, eating behavior, and mental health. Exploratory factor analysis of the WBIS-M and the BPSS supported a two-factor solution, although two items from the WBIS-M loaded with BPSS items. After removing these items, the 9-item version of the WBIS-M demonstrated stronger relationships with dysfunctional eating and mental health symptoms than did the BPSS (ꞵ range = 0.32-0.62 vs. 0.01-0.18, respectively). Findings from this study provide evidence to support the validity of WBIS-M and BPSS measuring unique constructs, suggesting that internalized weight stigma can be differentiated from body dissatisfaction. This study also highlights the need for further research that examines current measurement tools for internalized weight stigma and body dissatisfaction.

Longitudinal associations of binge eating with internalized weight stigma and eating self-efficacy.

INTRODUCTION: Internalized weight stigma (IWS) is linked to binge eating disorder (BED) symptoms and reduced self-efficacy, yet it unknown how changes in these factors may interrelate. The current study examined cross-sectional and longitudinal associations of BED with IWS and eating self-efficacy among treatment-seeking adults with high body weight. Disinhibited eating was explored as a mediator. METHODS: Seventy-one adults with high weight and elevated IWS were included in this secondary analysis of a clinical trial that provided 26 weeks of behavioral weight loss (BWL) treatment with (versus without) an additional IWS intervention. Participants underwent a BED diagnostic interview at screening and completed validated measures of binge eating, IWS (including weight bias internalization, self-devaluation, and stereotype endorsement), eating self-efficacy, and disinhibited eating at baseline and week-26. Cross-sectional mediation models tested associations of BED with IWS and eating self-efficacy, explained by disinhibited eating. Linear and logistic regression models, controlling for treatment condition, tested if baseline BED predicted changes in IWS, self-efficacy, and disinhibited eating, and if decreased binge episodes were associated with improved outcomes. RESULTS: At baseline, disinhibited eating mediated the relationship between BED and weight self-devaluation (95 % CI = 0.66,3.58), stereotype endorsement (CI = 0.15,0.56), and eating self-efficacy (CI:-14.40,-4.29). Baseline BED did not predict changes in outcomes. Participants with decreased binge episodes reported greater improvements in weight bias internalization (p = 0.04) and eating self-efficacy (p < 0.001). CONCLUSION: This study provides novel evidence of longitudinal associations between binge eating, IWS, and eating self-efficacy. IWS warrants further consideration as a treatment target and outcome in studies of BWL and BED.

Development of a cognitive-behavioral intervention for internalized weight stigma.

Individuals with a higher body weight are the targets of pervasive social stigma. This stigma can become self-directed or internalized, leading to self-devaluation due to weight. Internalized weight stigma is associated with adverse outcomes for mental and physical health, yet little is known about how to prevent or diminish this internalization. This article introduces a novel, group-based, psychological intervention designed to reduce internalized weight stigma and its ill effects on health. Rationale is provided for the therapeutic approach and for the intervention's proposed utility in behavioral weight management settings. Intervention content is described in detail, along with preliminary evidence of its potential effects on psychological and behavioral outcomes.

Long-term effects of an internalized weight stigma intervention: A randomized controlled trial.

OBJECTIVE: To test the long-term effects of a group-based, psychological intervention designed to reduce internalized weight stigma (IWS, i.e., self-stigma), delivered in combination with behavioral weight loss (BWL) treatment, compared to BWL alone. METHOD: Adults with obesity who had experienced and IWS (N = 105, Mage = 49 years, 90.5% women, 70.5% White, 24.8% Black, MBMI = 38 kg/m²) were randomized to receive BWL with the Weight Bias Internalization and Stigma (BIAS) Program or BWL alone. Participants received weekly group treatment for 20 weeks, followed by 52 weeks of monthly and every-other-month sessions. Percent weight change at Week 72 was the primary outcome, with secondary outcomes of weight change at other time points; physical activity (measured by accelerometry, interview, and self-report); cardiometabolic risk factors; and psychological and behavioral outcomes. Intention-to-treat analyses used linear mixed models to test for between-group differences. Treatment acceptability was assessed. RESULTS: Participants in the BWL + BIAS versus BWL group lost 2 percentage points more of baseline weight at Week 72, which was not a significant difference (mean weight change = -7.2% vs. -5.2%, 95% CI [-4.6 to 0.6], p = 0.14, d = 0.18). The BWL + BIAS (vs. BWL) group produced significantly greater improvements in weight self-stigma, eating self-efficacy, and some aspects of quality of life at specific time points. Most outcomes improved significantly over time but did not differ between groups. The trial had high retention and treatment acceptability, with higher ratings in the BWL + BIAS versus BWL group. CONCLUSIONS: No significant differences in weight loss were observed between the BWL + BIAS versus BWL group. Possible benefits of addressing weight stigma in weight management warrant further investigation. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Refining the conceptualization and assessment of internalized weight stigma: A mixed methods approach.

Internalized weight stigma has gained increasing attention in empirical studies, though questions remain about the adequacy of existing measures. The current study utilized a mixed methods approach, including a novel semi-structured interview, to revisit the conceptualization of internalized weight stigma and explore in more depth the stereotypes and impacts of weight reported by individuals with high scores on the widely-used Weight Bias Internalization Scale. All participants were interviewed as part of the screening procedures for two clinical trials (Study 1 n = 84, mean age=47.8 years, 83.3% women, 67.9% Black, mean BMI=39.2 kg/m2; Study 2 n = 129, mean age=50.0 years, 88.4% women, 65.1% white, mean BMI=37.8 kg/m2). The most common weight stereotypes identified were being lazy, lacking willpower or self-control, and having poor eating habits. Up to 66% of participants reported that they did not endorse negative weight stereotypes or apply them to themselves. The most highly identified impacts of weight were on self-image (>70%) and emotions (68-83%), followed by social (37-62%) and health concerns (20-25%). Approximately 60% of participants indicated that weight affected their self-directed thoughts and feelings "very much" to "extremely." Findings have implications for understanding and assessing internalized weight stigma in research and in clinical settings where interventions are needed.

Binge eating disorder and eating self-efficacy in adults seeking bariatric surgery.

This study assessed the relationships between binge eating disorder (BED) and eating self-efficacy in a sample of patients prior to bariatric surgery. The study also examined the extent that BED status accounted for variance in self-efficacy after controlling for demographic factors (age, sex and race), physical variables (comorbidities and body mass index [BMI]) and depressive symptoms. This was a cross-sectional study of pre-surgical data from patients seeking bariatric surgery at a university-based healthcare system (N = 98; mean ± SD age of 46.2 ± 12.5 years; BMI of 45.4 ± 7.2 kg/m2 ; 86.7% female; and 60.2% of patients self-identified as White). Patients completed the Weight and Lifestyle Inventory (WALI), Beck Depression Inventory-II (BDI-II) and Weight Efficacy Lifestyle Questionnaire. Of the total sample, 15.3% met criteria for BED, 33.7% had subthreshold BED and 51.0% were free of this disorder. In adjusted analyses, total self-efficacy was significantly lower in patients with subthreshold BED (B ± SE = -15.88 ± 7.23, p = .03) and individuals with BED (B ± SE = -35.07 ± 10.23, p = .001) than in those without BED. Patients with BED, compared to those without, had significantly worse scores (in adjusted analyses) on the self-efficacy subscales of negative emotions (p = .003), availability of food (p < .001), social pressure (p = .004) and positive activities (p = .03). In patients seeking bariatric surgery, total self-efficacy scores were significantly lower in patients with BED and subthreshold BED than those without BED. The results suggest that eating self-efficacy may be an important factor to target in patients with BED who seek bariatric surgery.

Mutations in SARS-CoV-2 variants of concern link to increased spike cleavage and virus transmission.

SARS-CoV-2 lineages have diverged into highly prevalent variants termed "variants of concern" (VOCs). Here, we characterized emerging SARS-CoV-2 spike polymorphisms in vitro and in vivo to understand their impact on transmissibility and virus pathogenicity and fitness. We demonstrate that the substitution S:655Y, represented in the gamma and omicron VOCs, enhances viral replication and spike protein cleavage. The S:655Y substitution was transmitted more efficiently than its ancestor S:655H in the hamster infection model and was able to outcompete S:655H in the hamster model and in a human primary airway system. Finally, we analyzed a set of emerging SARS-CoV-2 variants to investigate how different sets of mutations may impact spike processing. All VOCs tested exhibited increased spike cleavage and fusogenic capacity. Taken together, our study demonstrates that the spike mutations present in VOCs that become epidemiologically prevalent in humans are linked to an increase in spike processing and virus transmission.

Adverse Childhood Experiences and Weight Stigma: Co-Occurrence and Associations with Psychological Well-Being.

Prior research has demonstrated that individuals with a higher body weight (i.e., obesity) have a relatively high incidence of adverse childhood experiences (ACEs) (e.g., abuse, neglect). Individuals with obesity are also susceptible to experiencing and internalizing weight stigma. Negative physical and mental health consequences have been associated with both ACEs and weight stigma, yet the interplay between these factors has not been explored. The current study examined ACEs in a sample of 105 treatment-seeking adults with obesity who all reported having experienced and internalized weight stigma (90.5% women, 70.5% non-Hispanic White, mean age=49.1 years). The study aimed to 1) provide a descriptive overview of rates of ACEs in this unique sample of adults with potentially high psychological vulnerability and 2) assess associations between ACEs, weight stigma, and psychological well-being. Over three-fourths of participants (76.2%) reported experiencing at least one ACE. The total number of ACEs was significantly associated with more frequent experiences of and greater distress about weight stigma during childhood, as well as higher current perceived stress. Experiencing weight stigma for the first time in childhood was also associated with more reported ACEs. ACEs of abuse were associated with more lifetime reported experiences of weight stigma and greater internalization, use of eating as a strategy to cope with weight stigma, and higher perceived stress. These findings have implications for early identification of and tailored interventions for individuals who have experienced adverse events and weight stigma at a young age.

Is weight stigma associated with physical activity? A systematic review.

OBJECTIVE: Weight stigma is associated with impaired health, attributed in part to reductions in health-promoting behaviors. This review analyzed evidence of the association between weight stigma and physical activity (PA) in adults and youth. METHODS: Three databases were searched for terms related to weight stigma and PA. Eligible studies reported the quantitative association between at least one measure of weight stigma and one behavioral measure of PA. RESULTS: A total of 38 studies met eligibility criteria. Of the 29 studies of adults, 3 used objective PA measures, and 79% used an observational, cross-sectional design. Findings of the relationship between weight stigma and PA were mixed. Everyday weight discrimination and internalizing weight stigma were associated with reduced PA in most studies. Several studies found indirect, and not direct, effects of weight stigma on PA when analyses included other individual-level factors. In the nine studies of youth, two used objective PA measures, all were observational, and only one study was longitudinal. Most youth studies found a relationship between weight-based teasing and reduced PA. CONCLUSIONS: Weight teasing, everyday discrimination, and internalization were associated with reduced PA. However, associations were inconsistent and often indirect. Future studies should include objective PA measures with larger samples and longitudinal assessments.

Policies to address weight discrimination and bullying: Perspectives of adults engaged in weight management from six nations.

OBJECTIVE: Across the world, it remains legal to discriminate against people because of their weight. Although US studies demonstrate public support for laws to prohibit weight discrimination, multinational research is scarce. The present study conducted a multinational comparison of support for legislative measures to address weight discrimination and bullying across six countries. METHODS: Participants were adults (n = 13,996) enrolled in an international weight-management program and residing in Australia, Canada, France, Germany, the UK, and the US. Participants completed identical online surveys that assessed support for antidiscrimination laws and policies to address weight bullying, demographic characteristics, and personal experiences of weight stigma. RESULTS: Across countries, support was high for laws (90%) and policies (92%) to address weight-based bullying, whereas greater between-country variation emerged in support for legislation to address weight-based discrimination in employment (61%, 79%), as a human rights issue (57%), and through existing disability protections (47%). Findings highlight few and inconsistent links between policy support and sociodemographic correlates or experienced or internalized weight stigma. CONCLUSIONS: Support for policies to address weight stigma is present among people engaged in weight management across Westernized countries; findings offer an informative comparison point for future cross-country research and can inform policy discourse to address weight discrimination and bullying.

International comparisons of weight stigma: addressing a void in the field.

BACKGROUND/OBJECTIVES: Despite substantial evidence documenting weight stigma toward people with higher body weight, international comparative studies are lacking in this field. The few studies that have compared weight stigma across different countries focus on explicit weight-biased attitudes rather than people's experiences of weight stigma. The present study conducted a multinational systematic comparison of weight stigma in six countries to assess experiences and interpersonal sources of weight stigma. SUBJECTS/METHODS: Adults (N = 13,996) enrolled in WW International (formerly Weight Watchers), residing in Australia, Canada, France, Germany, the UK, and the US completed identical online anonymous surveys in the dominant language for their country. Surveys assessed their history of experiencing weight stigma, the onset of stigmatizing experiences and associated distress from stigma in different time periods, and interpersonal sources of weight stigma. RESULTS: More than half of participants (55.6-61.3%) across countries reported experiencing weight stigma. Participants with higher BMI were significantly more likely to report weight-stigmatizing experiences than individuals with lower BMI. In all countries, weight stigma experiences were most frequent in childhood and adolescence, with associated distress highest during these time periods. Participants in Germany reported a higher frequency of weight stigma across their whole life, but lower distress associated with stigmatizing experiences, compared to participants in the other five countries. High percentages of participants in each country experienced weight stigma from family members (76.0-87.8%), classmates (72.0-80.9%), doctors (62.6-73.5%), co-workers (54.1-61.7%), and friends (48.8-66.2%). CONCLUSIONS: Weight stigma is prevalent for adults actively engaged in weight management across different Western countries. There were more similarities than differences in the nature, frequency, and interpersonal sources of people's experiences of weight stigma across the six countries in this study. Findings underscore the need for multinational initiatives to address weight stigma and interventions to support individuals engaged in weight management who experience weight mistreatment.

Eating and Exercise-Related Correlates of Weight Stigma: A Multinational Investigation.

OBJECTIVE: Weight stigma is prevalent across the world. However, little is known about whether and how the harmful health consequences of weight stigma may vary across countries. The current study examined the association between experiences of weight stigma and multiple eating and exercise-related indicators among a large, multinational sample of adults. METHODS: Adults enrolled in an international weight management program residing in Australia, Canada, France, Germany, the United Kingdom, and the United States completed identical Web-based surveys in the dominant language for their country. Participants (N = 13,996) reported on their personal experiences of weight stigma and health, including eating behaviors, attitudes toward exercise, and perceived stress. RESULTS: More than half of all participants in each country reported experiencing weight stigma. Participants who had experienced weight stigma reported engaging in more eating to cope, gym avoidance, and self-monitoring behaviors, as well as higher levels of stress and reduced eating self-efficacy. These associations were documented over and above sociodemographic characteristics and BMI and did not vary across countries. CONCLUSIONS: Study findings document uniform health-related correlates of weight stigma within a multinational context and underscore the need for global initiatives to curtail weight stigma in order to support population health.

Prevalence and correlates of weight bias internalization in weight management: A multinational study.

Weight bias internalization (WBI) is an understudied form of internalized stigma, particularly among treatment-seeking adults with overweight/obesity. The current study surveyed 13,996 adults currently engaged in weight management in the first multinational study of WBI. From May to July 2020, participants in six Western countries completed the Modified Weight Bias Internalization Scale (WBIS-M) and measures of weight change, health behaviors, psychosocial well-being, and health-related quality of life (HRQOL). Participants were majority white, female, middle-aged, and categorized as having overweight or obesity based on body mass index. Results showed higher mean WBIS-M scores among participants in the UK, Australia, and France than in Germany, the US, and Canada. Across all countries, and controlling for participant characteristics and experiences of weight stigma, WBIS-M scores were associated with greater weight gain in the past year. Participants with higher WBIS-M scores also reported poorer mental and physical HRQOL, less eating and physical activity self-efficacy, greater engagement in eating as a coping strategy, more avoidance of going to the gym, poorer body image, and greater perceived stress. Few interaction effects were found between experiences and internalization of weight stigma. Overall, the current findings support WBI as a robust correlate of adverse weight-related health indices across six Western countries. Prospective and experimental studies are needed to determine directionality and causality in the relationship between WBI and poor health outcomes.

Weight Bias During the COVID-19 Pandemic.

PURPOSE OF REVIEW: This review explores potential sources of weight bias and stigma during the COVID-19 pandemic, including "quarantine-15" messages and discussion of obesity in media and public health campaigns. We examine evidence of the effects of weight bias on well-being during the pandemic and highlight unanswered questions to be addressed in future research. RECENT FINDINGS: Studies that have investigated weight change during stay-at-home orders have yielded mixed findings and relied predominantly on self-reported retrospective recall, thus providing weak evidence of a widespread "quarantine-15" effect. No studies to date have evaluated the effects on weight stigma and health of obesity-focused COVID-19 media and public health messages. Individuals with a history of experiencing weight bias may be more vulnerable to binge eating and psychological distress during the pandemic. Weight bias and stigma during the COVID-19 pandemic, and their effects on health and well-being, warrant greater investigation and consideration in public health efforts.