TYPE Original Research PUBLISHED 18 September 2023 DOI 10.3389/fpsyg.2023.1209245 Assessment of obesity stigma and OPEN ACCESS discrimination among Spanish subjects with a wide weight range: EDITED BY Katsunori Nonogaki, Tohoku University, Japan REVIEWED BY Giorgia Varallo, the OBESTIGMA study University of Parma, Italy Nasr Chalghaf, University of Gafsa, Tunisia Enric Sánchez 1, Andreea Ciudin 2,3, Ana Sánchez 4, Ruth Zhuozhuo Shen, Sonsoles Gutiérrez-Medina 5, Nuria Valdés 6, Lilliam Flores 3,7, South China Normal University, China Amelia Marí-Sanchis 8, Fernando Goñi 9, Marta Sánchez 10, *CORRESPONDENCE Albert Lecube Joana Nicolau 11, Concepción Muñoz 12, Olaia Díaz-Trastoy 13, alecube@gmail.com Guillem Cuatrecasas 14, Silvia Cañizares 15,16, Marta Comas 2, RECEIVED 16 May 2023 ACCEPTED 04 September 2023 Carolina López-Cano 1 and Albert Lecube 1,3* on behalf of the PUBLISHED 18 September 2023 Spanish Society for the Study of Obesity (SEEDO) CITATION Sánchez E, Ciudin A, Sánchez A, 1 Obesity Unit, Endocrinology and Nutrition Department, University Hospital Arnau de Vilanova de Lleida, Gutiérrez-Medina S, Valdés N, Flores L, Obesity, Diabetes and Metabolism (ODIM) Research Group, IRBLleida, University of Lleida, Lleida, Spain, Marí-Sanchis A, Goñi F, Sánchez M, Nicolau J, 2 Obesity Unit, Endocrinology and Nutrition Department, Hospital Universitari Vall d’Hebrón, Vall Muñoz C, Díaz-Trastoy O, Cuatrecasas G, d’Hebron Research Institute, Autonomous University of Barcelona, Barcelona, Spain, 3 Centro de Cañizares S, Comas M, López-Cano C and Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Lecube A (2023) Assessment of obesity stigma Instituto de Salud Carlos III (ISCIII), Madrid, Spain, 4 Obesity Unit, Endocrinology and Nutrition and discrimination among Spanish subjects Department, Complejo Hospitalario Universitario de Ferrol, Ferrol, Spain, 5 Obesity Unit, Endocrinology with a wide weight range: the OBESTIGMA and Nutrition Department, Hospital Universitario Rey Juan Carlos, Madrid, Spain, 6 Obesity Unit, study. Endocrinology and Nutrition Department, Hospital Universitario de Cabueñes, Gijón, Spain, 7 Obesity Front. Psychol. 14:1209245. Unit, Endocrinology and Nutrition Department, Hospital Clínic Barcelona, Barcelona, Spain, 8 Obesity doi: 10.3389/fpsyg.2023.1209245 Unit, Endocrinology and Nutrition Department, Hospital Universitario de Navarra, Pamplona, Spain, 9 Obesity Unit, Endocrinology and Nutrition Department, Hospital Universitario de Basurto, Bilbao, Spain, COPYRIGHT 10 Obesity Unit, Endocrinology and Nutrition Department, Hospital Universitario Doctor Negrín, Las © 2023 Sánchez, Ciudin, Sánchez, Gutiérrez- Palmas de Gran Canaria, Spain, 11 Obesity Unit, Endocrinology and Nutrition Department, Hospital Medina, Valdés, Flores, Marí-Sanchis, Goñi, Universitario Son Llàtzer, Palma, Spain, 12 Obesity Unit, Endocrinology and Nutrition Department, Sánchez, Nicolau, Muñoz, Díaz-Trastoy, Hospital Universitario Reina Sofia de Córdoba, Córdoba, Spain, 13 Obesity Unit, Endocrinology and Cuatrecasas, Cañizares, Comas, López-Cano Nutrition Department, Complejo Hospitalario Universitario de Pontevedra, Pontevedra, Spain, 14 Obesity and Lecube. This is an open-access article Unit, Endocrinology and Nutrition Department, Clínica Sagrada Familia-CPEN Barcelona, Health distributed under the terms of the Creative Science Department, UOC University, Barcelona, Spain, 15 Obesity Unit, Psychiatry and Psycology Commons Attribution License (CC BY). The Department, Hospital Clínic Barcelona, Barcelona, Spain, 16 Clinical Psycology and Psycobiology use, distribution or reproduction in other Department, Universitat de Barcelona, Barcelona, Spain forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or Introduction: This study aims to assess the extent of rejection and instances of reproduction is permitted which does not stigmatization linked to obesity within the Spanish population, encompassing comply with these terms. a diverse spectrum of weights ranging from normal weight to morbid obesity. Additionally, the study seeks to identify the primary factors influencing these experiences and further examines the impact of bariatric surgery on such dynamics. Materials and methods: Multicenter observational study with involving a total of 1,018 participants who were recruited from various Obesity Units. Negatives attitudes towards people with obesity were assessed through three questionnaires: (i) Antifat Attitudes Scale (AFA), (ii) Stigmatizing Situations Inventory (SSI) and (iii) Weight Bias Internalization Scale (WBIS). Subjects were categorized into four groups based on their BMI and history of prior bariatric surgery. Results: The cumulative score across all questionnaires (AFA, SSI and WBIS) exhibited a progressive increase, from participants with normal weight to those with obesity (p < 0.001 for all). Within the AFA questionnaire, males showed more rejection towards people with obesity than women, also perceiving obesity as Frontiers in Psychology 01 frontiersin.org Sánchez et al. 10.3389/fpsyg.2023.1209245 a disease linked to a lack of willpower (p = 0.004 and p = 0.030, respectively). The overall SSI score was negatively associated with age (r = −0.080, p = 0.011), with young participants encountering more stigmatizing experiences than their adult counterparts. Neither employment status nor educational demonstrated a significant association with any of the questionnaires. Interestingly, patients who underwent lost weight following bariatric surgery did not exhibit improved outcomes. Conclusion: Individuals with obesity demonstrate a heightened level of aversion towards the disease compared to those with normal weight. Concurrently, the incidence of stigmatizing encounters displays a concerning escalation among younger individuals. KEYWORDS stigma, discrimination, weight bias, obesity, bariatric surgery Introduction (Teachman et al., 2003; Jáuregui Lobera et al., 2008). In this way, data from a large representative telephone survey in Germany Obesity is a chronic and relapsing disease that has acquired demonstrated an overall prevalence of weight-based discrimination epidemic dimensions in the current era, due to its epidemiology that of 7.3%, which increased four-fold to 18.7% in participants with a affects more than 20% of the world population (Hales et al., 2020). body mass index between 35.0 and 39.9 kg/m2 (Spahlholz et al., Obesity can be defined using the body mass index, which is a simple 2016). Altogether, stigma in the context of obesity, can be described and widely utilized measure calculated by dividing a person’s weight as the social and psychological process of discrediting and devaluing in kilograms by the square of their height in meters. In the last individuals due to their weight, leading to negative stereotypes and 30 years, investigations have revealed that weight gain is significantly discrimination. This phenomenon can have profound effects on influenced by biopsychosocial factors, which often surpass various aspects of an individual’s life, including mood, body image, individual decisions and accountability (Masood and Moorthy, and even job opportunities (Vadiveloo and Mattei, 2017). It is 2023). So, multiple genes interacts with elements such as physical important to note that social discrimination and the feeling of inactivity, excessive calorie consumption, conditions during prenatal rejection perceived by people with obesity have a potential effect on development, post-birth influences, inadequate sleep, medication the lack of follow-up and adherence to dietary-behavioral treatment. usage, medical conditions, socioeconomic standing, ethnic In a cross-sectional study conducted on a sample of 5,129 people in background, psychological stress, the impact of endocrine- the United States, weight discrimination was clearly associated with disrupting chemicals, and the composition of the gastrointestinal overeating, more frequent consumption of prepared foods, and less microbiome to promote weight gain (Lin and Li, 2021; Masood and regular meal timing (Sutin et al., 2016). Interestingly, weight stigma Moorthy, 2023). This chronic, relapsing, and multifactorial disease may persist even substantive weight loss following bariatric surgery in its origin not only has a direct negative impact in the quality of procedures, a set of surgical interventions designed to treat obesity life of patients, as it can affect various aspects of physical function, and medical conditions related to excess weight (Dimitrov Ulian sexual life, self-steem, and social well-being, leading to a range of et al., 2023). This data suggest that the achievement of a thinner body challenges and limitations (Caixàs et al., 2013). In addition, obesity is not always free to be associated with perceived negative judgment also can shorten their life expectancy because it is the gateway to and condemnation by others. other diseases such as type 2 diabetes, cardiovascular disease, and As weight bias is an issue that is becoming increasingly some types of cancer (Di Angelantonio et al., 2016; Caballero, 2019). important in the holistic approach to patients with obesity, reducing In the same way, obesity causes a great economic impact, both due negative attitudes, beliefs, and stigmatization due to obesity would to direct health costs and indirect costs secondary to decreased be a key factor in the battle against this growing public health productivity, work absenteeism, and total disability (Destri concern. However, the information of the Spanish population on the et al., 2022). discrimination and stigmatization suffered by people with obesity is There is increasing evidence linking obesity with higher still scarce. Hence, our aim was to address this gap by investigating prevalence of mood disorders such as anxiety and depression the level of rejection and experiences of stigma related to obesity compared with the normal-weight population, especially in women within the Spanish population, encompassing individuals with a in a society fueled by the cult of thinness (Daníelsdóttir et al., 2010; diverse spectrum of weights, ranging from normal weight to morbid Sikorski et al., 2016; Spahlholz et al., 2016). But people living with obesity. For this purpose, we administered three well-validated obesity are also subject to discrimination, prejudice, and negative questionnaires as the Antifat Attitudes Scale (AAS), Stigmatizing attitudes in society because of their weight (Vadiveloo and Mattei, Situations Inventory (SSI) and the Weight Bias Internalization Scale 2017). Negative adjectives such as “clumsy,” “lazy,” “vulgar,” “rejected” (WBIS) (Crandall, 1994; Myers and Rosen, 1999; Durso and Latner, and “lonely” have been largely used to define people with obesity 2008). Furthermore, we sought to identify the primary factors Frontiers in Psychology 02 frontiersin.org Sánchez et al. 10.3389/fpsyg.2023.1209245 associated with these outcomes and examine the impact of bariatric prejudice against people with obesity in the United States. The surgery (BS). scale is a numerical response scale, with a range between 1 (“not at all agree”) and 7 (“strongly agree”). It includes 13 questions divided into three subscales: dislike (rejection towards people Methods with overweight or obesity), fear of being fat (fear of gaining weight) and willpower (weight is controllable). To obtain the Ethic statement score, the average of all the responses of each subscale and the global one were calculated. High scores on this scale are associated This study protocol was reviewed and approved by the ethics with strong attitudes against obesity. The validated version in committee of the Arnau de Vilanova University Hospital, approval Spanish of the AFA, with a good reliability results (Cronbach’s number CEIC-2190. In this study, the ethical guidelines of the alphas of 0.78, 0.87, and 0.81 for dislike, fear of being fat and Declaration of Helsinki and Spanish legislation on the protection of willpower respectively) was used (Molero et al., 2012; Macho personal data have also been followed. Participants were asked to join et al., 2022). voluntarily and were not awarded any financial or other compensation. The SSI is one of the most used methods to measure the Written informed consent was obtained from all subjects who agreed weight stigma experiences, but it may be impractical due to its to take part in the study before completing the questionnaires. length (Myers and Rosen, 1999). Consequently, the brief version of the SSI is a more efficient tool for assessing experiences with weight-related stigma (Cronbach’s alphas in different samples Study design and data collection ranging from 0.94 to 0.98) (Vartanian, 2015). This questionnaire assesses the stigmatizing experiences associated with being The OBESTIGMA study is a cross-sectional observational study overweight that may have occurred to a subject at least once in in which we analyzed data from 1,126 participants collected his/her lifetime. The result is obtained by calculating the average between January 2019 and December 2021. Men and women aged of all responses. The higher the score, the greater the number of 18 years or older and a body mass index (BMI) equal or greater than exposures to stigmatizing experiences. 18.5 kg/m2 were recruited from 13 Obesity Units in Spain. Patients The WBIS is a useful tool for assessing prejudice about who attended medical check-ups for their obesity, as well as their overweight. This questionnaire identifies patients who need companions, were included. A total of 57 participants were excluded medical help to deal with weight stigma and had high internal due to serious illness that determined a life expectancy of less than consistency (Cronbach’s alphas = 0.90) (Durso and Latner, 2008). 6 months, intellectual disability and psychiatric illness not Composed of 11 items, it measures the degree to which the considered stable and/or failure to report weight and height. In respondents believes that negative stereotypes about people with addition, 51 patients refused to participate in the study (response overweight and obesity apply to themselves. Responses range from rate of 95.4%). Consequently, the final sample consisted of “strongly disagree” to “strongly agree.” Items 1 and 9 should 1,018 participants. be scored reversely. The final score is obtained by calculating the Weight and height data were obtained on the same day of the average of all responses. High scores on the WBIS are related to interview. Based on these data, the body mass index was calculated, strong anti-obesity attitudes. and the respondents were classified into one of the following three groups: (i) subjects with healthy weight (from 18.5 to 24.9 kg/m2); (ii) overweight subjects (from 25.0 to 29.9 kg/m2); and (iii) subjects with Statistical analysis obesity (≥30.0 kg/m2). Additionally, participants who reported having undergone bariatric surgery previously were categorized into a distinct Statistical analyzes were performed using SSPS statistical package fourth group. In addition to weight and height, the following (IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY, USA). information was recorded: age, sex, marital status, ethnicity, The normal distribution of the variables was evaluated using the employment status, educational level, annual income, and self- Shapiro–Wilk test. Given their normal distribution, quantitative data perception of weight. are expressed as the mean ± SD. Comparisons between groups were To ensure the independence, accuracy, and honesty of their made using the ANOVA test for quantitative variables and Pearson’s responses, participants were given standardized verbal instructions. chi-squared for categorical variables. The relationship between They were informed that there were no right or wrong answers, and continuous variables was evaluated using the Pearson’s correlation that their responses would remain anonymous and confidential. Data test. Three multivariable logistic regression models (enter mode) were collection took place in the outpatient waiting room. The majority of performed to evaluate the results of the questionnaires, including the participants took 10–15 min to complete the survey. following confounding factors in the analysis: age, sex, BMI, employment status, and educational level. Model calibration was assessed using the Chi-squared goodness-of-fit test. All “P” values Assessment of negatives attitudes toward were based on a two-sided test of statistical significance. The people with obesity traditional significance level of p < 0.05 was chosen to find a middle ground between reducing false positive (Type I) errors and avoiding Three questionnaires were administered to all participants. missing real effects (Type II) errors. The level of 0.05 was applied to The AFA is a tool developed by Crandall (1994) to measure all statistical analyses. Frontiers in Psychology 03 frontiersin.org Sánchez et al. 10.3389/fpsyg.2023.1209245 TABLE 1 Main clinical data of the study population according to their weight classification and those who underwent bariatric surgery. Normal weight Overweight Obesity Bariatric surgery P (n = 173) (n = 134) (n = 572) (n = 139) BMI (kg/m2) 21.7 ± 1.9 27.2 ± 1.4 41.9 ± 7.4 33.5 ± 6.8 <0.001 Female, n (%) 135 (78.0) 89 (66.4) 398 (69.6) 108 (77.7) 0.029 Age (years) 39.7 ± 14.1 47.1 ± 13.5 48.3 ± 11.5 50.5 ± 10.0 <0.001 Caucasian, n (%) 127 (73.4) 91 (68.4) 385 (67.5) 87 (63.0) 0.692 Married, n (%) 106 (61.3) 97 (72.4) 372 (65.0) 103 (74.1) 0.018 Housewife, n (%) 6 (3.5) 9 (6.7) 125 (21.9) 35 (25.2) <0.001 Unemployment, n (%) 14 (8.1) 14 (10.4) 125 (21.9) 35 (25.2) <0.001 University studies, n (%) 120 (69.4) 58 (43.3) 134 (23.4) 25 (18.0) <0.001 Income <20.000€, n (%) 87 (50.6) 77 (57.5) 348 (61.3) 99 (71.2) 0.065 Data are n (percentage) and mean and standard deviation; BMI, body mass index; €, euros. TABLE 2 Scoring of the questionnaires according to the BMI of the study population. Normal weight Overweight Obesity Bariatric surgery P (n = 173) (n = 134) (n = 572) (n = 139) AFA 33.7 ± 12.0 35.5 ± 11.0 38.6 ± 12.1 37.8 ± 12.5 <0.001 AFA_dislike 13.8 ± 6.4 13.1 ± 6.0 13.4 ± 7.3 13.6 ± 7.6 0.821 AFA_fear of being fat 8.7 ± 4.6 10.2 ± 4.9 13.8 ± 5.4 14.2 ± 5.4 <0.001 AFA_willpower 11.1 ± 4.3 12.1 ± 4.3 11.4 ± 4.9 10.2 ± 4.9 0.008 SSI 4.8 ± 9.6 11.8 ± 12.5 28.2 ± 17.7 27.7 ± 17.5 <0.001 WBIS 24.2 ± 11.5 30.2 ± 13.6 41.7 ± 15.2 40.9 ± 14.6 <0.001 Data are mean and standard deviation; AFA, Antifat Attitudes Scale; SSI, Stigmatizing Situations Inventory; WBIS, Weight Bias Internalization Scale. Results On the SSI questionnaire, the number of exposures to stigmatizing experiences increased progressively with weight across the three The detailed data for the 1,018 participants in the study, groups. It is important to note that the overall SSI score was negatively encompassing demographic, social, and economic characteristics, is associated with age, demonstrating that young participants presented in Table 1. It is observed that the progression through the experienced significantly more stigmatizing experiences than adults BMI categories, from normal weight to obesity, was associated with (r = −0.080, p = 0.011). In individuals with obesity, the three items increments in the age of participants and the percentage of women, from the SSI questionnaire that received higher scores were “Having married, unemployed, participants without a university education people assume you overeat or binge eat because you are overweight” and housewife. (negative assumption domain), “Not being able to find clothes that fit” The scores obtained in the three questionnaires (AFA, SSI, and (physical limitation donain), and “Being stared at in públic” (being WBIS) are shown in Table 2. In the AFA questionnaire, the total score stared at domain). progressively increased from participants with normal weight to In the WBIS questionnaire, our observations revealed that participants with obesity. When the three subscales of the AFA were individuals with obesity tend to more frequently attribute negative analyzed, different results were observed. Both the fear of being fat stereotypes to themselves. This inclination stems from a greater and willpower subscales showed a similar increase through BMI like internalized bias toward obesity when compared to groups with lower the global score. However, antipathy towards obesity (dislike subscale) weights. Finally, like the AFA questionnaire, the effect of bariatric does not vary between the different groups. Finally, the results in the surgery did not affect the perception of patients regarding global score and in the three subscales were similar when patients who stigmatizing situations and the internalization of weight bias. underwent bariatric surgery were considered. In the bivariate analysis, BMI was significantly correlated with When analyzing the results of the AFA questionnaire through a the total score of AFA (r = 0.171, p < 0.001), SSI (r = 0.522, p < 0.001) gender lens, significant disparities emerged once more. It was and WBIS (r = 0.417, p < 0.001) questionnaires (Figure 2). The observed that men exhibited a higher inclination towards disapproving multivariate analysis confirmed the differential role of BMI in all of individuals with overweight or obesity compared to women questionnaires (Table 3). In addition, the multivariate analysis also (p = 0.004) as depicted in Figure 1A. Moreover, men tended to confirmed the differential role of age in relation to SSI and gender in associate obesity with a lack of willpower (p = 0.030). Conversely, relation to AFA and WBIS. However, neither employment status nor women demonstrated a greater prevalence of fear concerning weight educational level were significant variables in any of the gain (p = 0.017) (Figure 1B). 3 questionnaires. Frontiers in Psychology 04 frontiersin.org Sánchez et al. 10.3389/fpsyg.2023.1209245 FIGURE 1 Results of the questionnaires according to four groups included in the study in female (A) and male (B) population. FIGURE 2 Bivariate correlations between body mass index and the three questionnaires. Discussion The main characteristics of the population encompassed in the OBESTIGMA study indicate that within participants with a BMI The OBESTIGMA study has measured prejudice against people ≥30 kg/m2, both those possessing university degrees and those with obesity and weight stigma in a large cohort of subjects with a engaged in active employment experienced a decline. It is well known wide range of BMIs in Spain. We have confirmed that individuals that mean BMI is higher among people with a lower lifetime living with obesity encounter a heightened occurrence of experiences socioeconomic status compared to those with a higher one, an related to weight-related stigma. Furthermore, individuals with higher association that is generally stronger among men than among women BMIs exhibit a pronounced belief that the prevailing biases about (Newton et al., 2017). Moreover, the prevalence of obesity has been obesity in our society are applicable to their own circumstances. associated with higher unemployment rates throughout Europe and However, we observed that rather than observing a diminished level in Spain (Diamantis et al., 2022). However, in our study, educational of prejudice toward individuals with obesity among those who are level and employment status do not seem to be independently related affected by the condition, our findings revealed the opposite trend: as to the perception of discrimination and stigma due to obesity. While the degree of obesity increased, so did the intensity of anti- this outcome might appear unexpected, a recent systematic narrative obesity attitudes. review of the existing literature aimed at evaluating the potential Frontiers in Psychology 05 frontiersin.org Sánchez et al. 10.3389/fpsyg.2023.1209245 TABLE 3 A multivariable logistic regression model for total score of questionnaires in the whole population. β Beta 95% CI P Antifat attitudes scale (AFA) Age −0.057 – 0.213 Sex (M/F) −3.074 −2.54 (−5.45 to −0.69) 0.011 BMI (kg/m ) 2 0.143 0.12 (0.02 to 0.26) 0.011 Employment status (Active/Unemployement) 0.918 – 0.081 Educational level (Basic/University) −0.026 – 0.962 Constant 38.83 (29.97 to 47.68) <0.001 R = 0.044 2 Stigmatizing situations inventory (SSI) Age −0.171 −0.12 (−0.30 to −0.41) 0.010 Sex (M/F) 3.077 – 0.081 BMI (kg/m2) 1.026 0.54 (0.85 to 1.19) <0.001 Employment status (Active/Unemployement) 0.097 – 0.899 Educational level (Basic/University) 0.327 – 0.678 Constant −12.49 (−25.32 to 0.33) 0.056 R = 0.272 2 Weight bias internalization scale (WBIS) Age –0.085 – 0.137 Sex (M/F) 3.096 0.09 (0.10 to 6.09) 0.043 BMI (kg/m ) 2 0.666 8.75 (0.52 to 0.82) <0.001 Employment status (Active/Unemployement) −0.390 – 0.556 Educational level (Basic/University) −0.884 – 0.200 Constant 16.24 (5.03 to 27.44) 0.005 R = 0.192 2 – influence of socioeconomic factors on weight-related stigma and them with higher education) online from the Spanish population. This discrimination yielded notably incongruent findings (Bernard et al., contrasts with the participants in the OBESTIGMA study, who were 2019). Among the eight studies conducted, six studies indicated a recruited within the clinical environment of Obesity Units. Therefore, notable correlation between weight bias and education or income, our results highlight the need for further research on anti-fat attitudes while the remaining two studies presented opposing results, and an using different samples to better understand the mechanism additional seven studies found no discernible association (Bernard explaining weight discrimination and maintenance. As men showed et al., 2019). more rejection towards people who were overweight or obese than Living with chronic illness is a complex, ever-evolving, cyclic, and women, this research will also require thinking about the gender multifaceted process (Ambrosio et al., 2015). In this way, obesity perspective considering the attitudes, hopes and aspirations of presents hurdles to psychosocial well-being and self-esteem, creating each gender. an ongoing and lifelong endeavor of embracing, coping, self- Stigmatizing weight experiences have a negative impact on management, as well as striving for integration and adaptation in the people’s health and social behavior and have been associated with face of this persistent and recurring condition (Christiansen et al., increased food intake in response to stress, increased exercise 2012; Ambrosio et al., 2015; Spahlholz et al., 2016). According to the avoidance, and increased perceived stress (Pearl et al., 2021). These AFA total score, patients with obesity had the strongest prejudices experiences could be grouped into direct (e.g., being abused when against being overweight, suggesting that much educational work using public transport), environmental (e.g., not being able to fit into remains to be done to increase acceptance of obesity among patients seats on planes), and indirect (e.g., people staring at the contents of living with the disease. Among the three subscales assessed by the their supermarket trolley) stigma (Link and Phelan, 2006). AFA questionnaire, both the apprehension about weight gain and the Interestingly, participants in the study of Lewis et al. (2011) described belief that obesity is influenced by individual control exhibited a direct that more subtle forms of stigma had the most impact on their health correlation with the escalation in BMI. These results seem to contrast and social wellbeing. As expected, in the OBESTIGMA study, negative with a recent study by Macho et al. (2022) in which people with weight experiences were more frequent among participants with normal weight were those who showed more anti-obesity attitudes. higher BMI. However, a worrying observation was that weight- This study recruited 1,248 participants (mean age 33.3 years, 66.5% of stigmatizing experiences were more frequent among younger Frontiers in Psychology 06 frontiersin.org Sánchez et al. 10.3389/fpsyg.2023.1209245 participants, suggesting that modern life is a barrier to favoring the encounters persist in participants even after significant weight integration of people with obesity in our society. This result is in line loss, and this may influence how they perceive their current with other two previous studies in nursing students, both in Turkey encounters (Bennett et al., 2022). Indeed, this is an important line and in the United States, which show how moderate levels of fat of research that needs to be continued to better understand the phobia and negative attitudes towards people with obesity persist even relationship between weight bias and bariatric surgery, among future health professionals (Darling and Atav, 2019; Usta et al., particularly longitudinally. 2021). These findings only reinforce the idea that anti-fat attitudes and Some limitations of our research should be noted. First, it is not stereotyped perceptions need to be addressed during the early stages clear whether a better definition of obesity, for example through of the education within the general population (Elboim-Gabyzon percentage body fat, would change our results. Additionally, some et al., 2020). of our participants self-reported their own weight and height, with The frequency and intensity of perceived weight discrimination the potential power to change our results (Lecube et al., 2020). limits all life projects (social, economic, educational, and Secondly, the cross-sectional design of our research hinders our psychological well-being) of people with obesity (Durso and Latner, ability to establish a causal relationship between attitudes towards 2008). In the WBIS questionnaire, we observed that individuals with obesity and the degree of excess weight. In addition, our study relies obesity more frequently adopt negative beliefs and opinions about solely on self-reported data, which may be subject to recall bias or themselves due to external judgments from society. When people social desirability bias. Third, it’s important to note that our study internalize weight stigma, negative emotional and physical health population was drawn from different obesity units, potentially consequences develop, regardless of BMI (Durso and Latner, 2008). influencing the characteristics of participants and limiting their This leads to increased odds of 5–10% weight gain, poorer weight representativeness to the broader population (Ashmore et al., 2008). control behaviors, less food control, and lower eating self-efficacy Lastly, unrecorded variables, including elements such as physical (Ashmore et al., 2008; Puhl et al., 2021). In this context, various activity, dietary habits, coexisting medical conditions, medications, research converges on the counterintuitive conclusion that not psychological factors, environmental influences, and the duration recognizing oneself as being overweight or obese may be associated of obesity, could potentially introduce confounding effects in our with more favorable physical and mental health outcomes than results. Undoubtedly, future studies in a more representative recognizing oneself as such (Robinson et al., 2020). A study population of the general population are necessary. conducted in the United States reported that approximately one in five adults in the general population and 52% of adults with obesity endorsed the highest levels of weight bias internalization. Those with Conclusion the highest weight bias internalization tended to be white, had lower levels of education and income, were actively attempting weight loss, The perception of obesity in Spain, encompassing both individuals and had higher BMIs, greater self-perceived weight, and prior with obesity and those with normal weight, is complex and divergent experiences of weight stigma, particularly teasing (Puhl et al., 2018). from our initial assumptions. Surprisingly, individuals with obesity However, the score on the WBIS questionnaire does not always exhibit a higher degree of aversion towards the disease compared to correlate with BMI in all studies, suggesting that the degree of the population with normal weight. Concurrently, the experience of internalization of weight bias does not necessarily depend on the stigmatizing encounters shows a worrying increase among younger degree of overweight of an individual (Durso and Latner, 2008). Our individuals. In light of these insights, mitigating negative attitudes, study’s multivariate analysis revealed a gender-specific role in relation beliefs, and stigmatization related to obesity emerges as a pivotal to WBIS, with men obtaining higher scores. However, this finding element in the ongoing battle against this escalating public health was not corroborated in the study by Puhl et al. (2018) where among concern. Lastly, it is noteworthy that bariatric surgery falls short of individuals with the highest weight bias internalization scores, 72.1% diminishing social stigma scores to levels equivalent to those observed were women. Therefore, understanding the implications of in individuals with normal weight. internalized stigma can illuminate how individuals with obesity perceive themselves, assess their self-worth, and explore how societal attitudes might become internalized within their self-concept. Data availability statement We did not find a significant reduction in the score of any of the 3 questionnaires in patients undergoing bariatric procedures The raw data supporting the conclusions of this article will compared with participants with obesity who did not undergo be made available by the authors, without undue reservation. surgery. These results are in line with the study by Raves et al., in which the percentage change in BMI after bariatric surgery had no effect on any measure of weight-related stigma (Raves et al., Ethics statement 2016). It has been suggested that this lack of change is related to the fact that, even after radical weight loss, patients on average The studies involving humans were approved by the ethics still fall into the obesity classification, which may not change the committee of the Arnau de Vilanova University Hospital, approval way society interacts with them (Bennett et al., 2022). In addition, number CEIC-2190. The studies were conducted in accordance patients who have chosen the surgical weight loss option run the with the local legislation and institutional requirements. The risk of being re-characterized as “lazy” or “low effort” subjects participants provided their written informed consent to participate (Fardouly and Vartanian, 2012). Third, memories of stigmatizing in this study. Frontiers in Psychology 07 frontiersin.org Sánchez et al. 10.3389/fpsyg.2023.1209245 Author contributions Conflict of interest ES and AC: conceptualization. AS and SG-M: data curation. ES and The authors declare that the research was conducted in the NV: formal analysis. LF and AM-S: investigation. FG and MS: absence of any commercial or financial relationships that could methodology. JN and CM: software. AL: project administration and be construed as a potential conflict of interest. supervision. OD-T, GC, and SC: visualization. ES: writing – original draft. MC, CL-C, and AL: writing – review and editing. All authors contributed to the article and approved the submitted version. Publisher’s note All claims expressed in this article are solely those of the authors Funding and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product The Spanish Society for the Study of Obesity (Sociedad Española that may be evaluated in this article, or claim that may be made by its de Obesidad, SEEDO) supported this study. manufacturer, is not guaranteed or endorsed by the publisher. References Ambrosio, L., Senosiain García, J. M., Riverol Fernández, M., Anaut Bravo, S., Díaz de Hales, C. M., Carroll, M. D., Fryar, C. D., and Ogden, C. L. (2020). Prevalence of Cerio Ayesa, S., Ursúa Sesma, M. E., et al. (2015). Living with chronic illness in adults: obesity and severe obesity among adults: United States, 2017-2018. NCHS Data Brief a concept analysis. J. Clin. Nurs. 24, 2357–2367. doi: 10.1111/jocn.12827 360, 1–8. Ashmore, J. A., Friedman, K. E., Reichmann, S. K., and Musante, G. J. (2008). Weight- Jáuregui Lobera, I., Rivas Fernández, M., Montaña González, M. T., and Morales based stigmatization, psychological distress, & binge eating behavior among obese Millán, M. T. (2008). The influence of stereotypes on obesity perception. Nutr. Hosp. 23, treatment-seeking adults. Eat. Behav. 9, 203–209. doi: 10.1016/j.eatbeh.2007.09.006 319–325. Bennett, B. L., Lawson, J. L., Funaro, M. C., and Ivezaj, V. (2022). Examining weight Lecube, A., Sánchez, E., Monereo, S., Medina-Gómez, G., Bellido, D., bias before and/or after bariatric surgery: a systematic review. Obes. Rev. 23:e13500. doi: García-Almeida, J. M., et al. (2020). Factors accounting for obesity and its perception 10.1111/obr.13500 among the adult Spanish population: data from 1,000 computer-assisted telephone interviews. Obes. Facts 13, 322–332. doi: 10.1159/000508111 Bernard, M., Fankhänel, T., Riedel-Heller, S. G., and Luck-Sikorski, C. (2019). Does weight-related stigmatisation and discrimination depend on educational attainment and Lewis, S., Thomas, S. L., Blood, R. W., Castle, D. J., Hyde, J., and Komesaroff, P. A. level of income? A systematic review. BMJ Open 9:e027673. doi: 10.1136/ (2011). How do obese individuals perceive and respond to the different types of obesity bmjopen-2018-027673 stigma that they encounter in their daily lives? A qualitative study. Soc. Sci. Med. 73, 1349–1356. doi: 10.1016/j.socscimed.2011.08.021 Caballero, B. (2019). Humans against obesity: who will win? Adv. Nutr. 10, S4–S9. doi: 10.1093/advances/nmy055 Lin, X., and Li, H. (2021). Obesity: epidemiology, pathophysiology, and therapeutics. Front. Endocrinol. (Lausanne) 12:706978. doi: 10.3389/fendo.2021.706978 Christiansen, B., Borge, L., and Fagermoen, M. S. (2012). Understanding everyday life of morbidly obese adults-habits and body image. Int J Qual Stud Health Well-being Link, B. G., and Phelan, J. C. (2006). Stigma and its public health implications. Lancet 7:17255. doi: 10.3402/qhw.v7i0.17255 367, 528–529. doi: 10.1016/S0140-6736(06)68184-1 Crandall, C. S. (1994). Prejudice against fat people: ideology and self-interest. J. Pers. Macho, S., Andrés, A., and Saldaña, C. (2022). Anti-fat attitudes among Spanish Soc. Psychol. 66, 882–894. doi: 10.1037/0022-3514.66.5.882 general population: psychometric properties of the anti-fat attitudes scale. Clin. Obes. 12. doi: 10.1111/cob.12543 Daníelsdóttir, S., O'Brien, K. S., and Ciao, A. (2010). Anti-fat prejudice reduction: a review of published studies. Obes. Facts 3, 47–58. doi: 10.1159/000277067 Masood, B., and Moorthy, M. (2023). Causes of obesity: a review. Clin. Med. (Lond.) 23, 284–291. doi: 10.7861/clinmed.2023-0168 Darling, R., and Atav, A. S. (2019). Attitudes toward obese people: a comparative study of nursing, education, and social work students. J. Prof. Nurs. 35, 138–146. doi: 10.1016/j. Molero, F., Recio, P., García-Ael, C., Fuster, M. J., and Sanjuán, P. (2012). Measuring profnurs.2018.07.009 dimensions of perceived discrimination in five stigmatized groups. Soc. Indic. Res. 114, 901–914. doi: 10.1007/s11205-012-0179-5 Destri, K., Alves, J., Gregório, M. J., Dias, S. S., Henriques, A. R., Mendonça, N., et al. (2022). Obesity-attributable costs of absenteeism among working adults in Portugal. Myers, A., and Rosen, J. C. (1999). Obesity stigmatization and coping: relation to BMC Public Health 22:978. doi: 10.1186/s12889-022-13337-z mental health symptoms, body image, and self-esteem. Int. J. Obes. Relat. Metab. Disord. 23, 221–230. doi: 10.1038/sj.ijo.0800765 Di Angelantonio, E., Bhupathiraju, S. N., Wormser, D., Gao, P., Kaptoge, S., de Gonzalez, A. B., et al. (2016). Body-mass index and all-cause mortality: individual- Newton, S., Braithwaite, D., and Akinyemiju, T. F. (2017). Socio-economic status over participant-data meta-analysis of 239 prospective studies in four continents. Lancet 388, the life course and obesity: systematic review and meta-analysis. PLoS One 12:e0177151. 776–786. doi: 10.1016/S0140-6736(16)30175-1 doi: 10.1371/journal.pone.0177151 Diamantis, D. V., Karatzi, K., Kantaras, P., Liatis, S., Iotova, V., Bazdraska, Y., et al. Pearl, R. L., Puhl, R. M., Lessard, L. M., Himmelstein, M. S., and Foster, G. D. (2022). Prevalence and socioeconomic correlates of adult obesity in Europe: the (2021). Prevalence and correlates of weight bias internalization in weight Feel4Diabetes study. Int. J. Environ. Res. Public Health 19:12572. doi: 10.3390/ management: a multinational study. SSM Popul Health 13:100755. doi: 10.1016/j. ijerph191912572 ssmph.2021.100755 Dimitrov Ulian, M., Fernandez Unsain, R., Rocha Franco, R., Aurélio Santo, M., Puhl, R. M., Himmelstein, M. S., and Quinn, D. M. (2018). Internalizing weight Brewis, A., Trainer, S., et al. (2023). Weight stigma after bariatric surgery: a qualitative stigma: prevalence and sociodemographic considerations in US adults. Obesity (Silver study with Brazilian women. PLoS One 18:e0287822. doi: 10.1371/journal.pone.0287822 Spring) 26, 167–175. doi: 10.1002/oby.22029 Durso, L. E., and Latner, J. D. (2008). Understanding self-directed stigma: development Puhl, R. M., Lessard, L. M., Pearl, R. L., Himmelstein, M. S., and Foster, G. D. (2021). of the weight bias internalization scale. Obesity (Silver Spring) 16, S80–S86. doi: 10.1038/ International comparisons of weight stigma: addressing a void in the field. Int. J. Obes. oby.2008.448 45, 1976–1985. doi: 10.1038/s41366-021-00860-z Elboim-Gabyzon, M., Attar, K., and Peleg, S. (2020). Weight stigmatization among Raves, D. M., Brewis, A., Trainer, S., Han, S. Y., and Wutich, A. (2016). Bariatric physical therapy students and registered physical therapists. Obes. Facts 13, 104–116. surgery patients' perceptions of weight-related stigma in healthcare settings impair doi: 10.1159/000504809 post-surgery dietary adherence. Front. Psychol. 7:1497. doi: 10.3389/ fpsyg.2016.01497 Fardouly, J., and Vartanian, L. R. (2012). Changes in weight bias following weight loss: the impact of weight-loss method. Int. J. Obes. 36, 314–319. doi: 10.1038/ijo.2011.26 Robinson, E., Haynes, A., Sutin, A., and Daly, M. (2020). Self-perception of overweight and obesity: a review of mental and physical health outcomes. Obes. Sci. Pract. 6, Group for the Study of Obesity of the Spanish Endocrinology and Nutrition Society 552–561. doi: 10.1002/osp4.424 (SEEN)Caixàs, A., Lecube, A., Morales, M. J., Calañas, A., Moreiro, J., et al. (2013). Weight-related quality of life in Spanish obese subjects suitable for bariatric surgery is Sikorski, C., Spahlholz, J., Hartlev, M., and Riedel-Heller, S. G. (2016). Weight-based lower than in their north American counterparts: a case-control study. Obes. Surg. 23, discrimination: an ubiquitous phenomenon? Int. J. Obes. 40, 333–337. doi: 10.1038/ 509–514. doi: 10.1007/s11695-012-0791-0 ijo.2015.165 Frontiers in Psychology 08 frontiersin.org Sánchez et al. 10.3389/fpsyg.2023.1209245 Spahlholz, J., Baer, N., König, H. H., Riedel-Heller, S. G., and Luck-Sikorski, C. (2016). Usta, E., Bayram, S., and Altınbaş Akkaş, Ö. (2021). Perceptions of nursing students Obesity and discrimination - a systematic review and meta-analysis of observational about individuals with obesity problems: belief, attitude, phobia. Perspect. Psychiatr. Care studies. Obes. Rev. 17, 43–55. doi: 10.1111/obr.12343 57, 777–785. doi: 10.1111/ppc.12613 Sutin, A., Robinson, E., Daly, M., and Terracciano, A. (2016). Weight discrimination and Vadiveloo, M., and Mattei, J. (2017). Erratum to: perceived weight discrimination and unhealthy eating-related behaviors. Appetite 102, 83–89. doi: 10.1016/j.appet.2016.02.016 10-year risk of allostatic load among US adults. Ann. Behav. Med. 51:105. doi: 10.1007/ s12160-016-9870-0 Teachman, B. A., Gapinski, K. D., Brownell, K. D., Rawlins, M., and Jeyaram, S. (2003). Demonstrations of implicit anti-fat bias: the impact of providing causal information and Vartanian, L. R. (2015). Development and validation of a brief version of the evoking empathy. Health Psychol. 22, 68–78. doi: 10.1037/0278-6133.22.1.68 stigmatizing situations inventory. Obes. Sci. Pract. 1, 119–125. doi: 10.1002/osp4.11 Frontiers in Psychology 09 frontiersin.org