End of Weight Stigma: A Proposal for a Multilevel Classification of its Components for Intervention Purposes

End of Weight Stigma: A Proposal for a Multilevel Classification of its Components for Intervention Purposes | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article End of Weight Stigma: A Proposal for a Multilevel Classification of its Components for Intervention Purposes Gabriela Cristina Arces de Souza, Maria Fernanda Laus, Fernanda Rodrigues de Oliveira Penaforte, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4660605/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Weight stigma is a complex construct formed by various components. This study aimed to compile these components and classify them into the multilevel intervention levels of stigma (structural, interpersonal, and intrapersonal). Methods A non-systematic literature review was conducted to identify the most commonly used definitions of weight stigma components. Subsequently, a proposal was made to classify these components into different intervention levels as proposed (Structural, Interpersonal, Intrapersonal). The components were categorized based on their definitions and specificities at each level. A panel of experts evaluated the proposal, and the degree of agreement was assessed using Fleiss' Kappa coefficient (₭). Values of ₭ between 0.40 and 0.60 indicated moderate agreement; between 0.61 and 0.75, good agreement; and above 0.75, excellent agreement. Results Ten terms were identified and classified in the different levels of stigma, except “Weight stigma” and “Weight bias”. At the structural level were included "fatphobia" and "weight-based stereotypes"; at the interpersonal level, "weight discrimination" and "explicit weight bias"; and at the intrapersonal level, "implicit weight bias", "lipophobia," "fat stigma", and "internalized weight bias". Agreement among the experts' responses for the structural and interpersonal levels was 100% (₭ = 1.0). For the components allocated at the intrapersonal level, there were some disagreements in the classification of the “Fat stigma” component (₭ = 0.4), and “Lipophobia” and “Implicit weight bias” were considered inappropriate by one specialist (₭ = 0.6). Conclusion The proposed classification of weight stigma components across multi-level interventions is novel and deemed appropriate by the experts. In future studies, this classification can help assess associations between weight stigma components across inter- and intra-levels and guide interventions across different levels for more effective outcomes in combating weight stigma. Obesity Weight Stigma Weight Bias Weight Discrimination Intervention Figures Figure 1 Plain English Summary Weight stigma has various components, and this study aimed to classify them across multiple intervention levels. The intervention levels are as follows: structural—components involved in the origin of stigma; interpersonal—components about interactions within small groups; and intrapersonal—components related to the individual. These components of weight stigma were compiled from a review of the scientific literature and classified into levels. This classification was submitted to a committee of experts on the subject. Expert consensus on the classification of terms was evaluated, and the final proposal was discussed. Ten terms were identified, and eight of them were classified as follows: at the structural level, "fatphobia" and "weight-based stereotypes"; at the interpersonal level, "weight discrimination" and "explicit weight bias"; and at the intrapersonal level, "implicit weight bias" "lipophobia" "fat stigma" and "internalized weight bias". There was complete agreement at the structural and interpersonal levels. At the intrapersonal level, there were disagreements regarding the classification of "fat stigma" "lipophobia" and "implicit weight bias" which one expert considered inappropriate. After evaluating and considering these perspectives, the classification remained unchanged. It is emphasized that there is a direct and bidirectional relationship between these levels, and this study may contribute to more targeted and effective interventions to combat weight stigma. Background As defined by Goffman [ 1 ], the stigma refers to an attribute that profoundly discredits its bearer, leading it to be seen as contaminated and scorned. Link & Phelan (2001) [ 2 ] further expanded this definition, describing stigma as a process of five interrelated components. First, there is labeling, where human differences are identified and labeled. Next comes labeling, in which these labels are associated with characteristics deemed undesirable by dominant cultural beliefs. This leads to separation, where labeled individuals become distinct from those who do not possess these undesirable characteristics. This differentiation results in the loss of status in society as stigmatized individuals begin to face discrimination. When these five components − (1) labeling, (2) negative attributes, (3) separation, (4) status loss, and (5) discrimination - unfold in this sequence, they converge to construct stigma [ 2 ]. The history of weight stigma is complex, and here, we will provide a brief contextualization to understand the topic's relevance. Initially associated with health and prosperity [3.4], body fat began to be blamed during the Classical era. This shift marked the beginning of labeling and stigmatizing fat bodies as undesirable [ 2 , 3 ]. From then on, beliefs and attitudes towards fat bodies started to change, intensifying the process of stigmatization. In the 19th century, Adolphe Quetelet sought to define the characteristics of the "average man" and developed the Quetelet index, later known as Body Mass Index (BMI), which is now used worldwide as a diagnostic criterion for obesity. In 1948, obesity was included in the International Classification of Diseases, reinforcing the pathologization of fat. However, there was no clinical evidence of a causal relationship between excess weight and associated comorbidities at that time. In 1998, the World Health Organization promoted BMI as a diagnostic and classification parameter for obesity [ 3 , 5 ]. Furthermore, psychology has played a significant role in this process by associating the fat body with overeating, depression, hypochondria, and melancholy, reinforcing the pathologization of fat since the 17th century and amplifying it with the advent of Freudian thought in the 1940s. This process further deepened the stigma associated with fat [ 4 , 6 ], which solidified over time. In this direction, fat ceases to be merely a physical characteristic and comes to be seen as a consequence of undisciplined behaviors, culminating in an unwanted physical identity. This process involved distinction, labeling, and loss of status [ 7 ]. Later, excess weight is characterized as a physiological disorder or disease, systematically pathologized and institutionalized as a medical issue [ 8 , 9 ]. Consequently, the fat body is arbitrarily and automatically elevated to the status of a diseased body [ 10 ]. Notably, this process co-occurred with the idealization of thinness, as described by Claude Fischler, who depicts an "almost manic rejection of obesity" [ 7 ]. The process of weight-related stigma itself entails various consequences for overweight individuals, including increased depression, anxiety, social isolation, and eating disorders; higher likelihood of developing dementia; elevated suicide rates; greater tendency towards sedentary behavior; metabolic changes; and avoidance of healthcare, including emergency services [ 11 , 12 ]. Given the significantly negative impact on the individual, the process of stigmatization, of any nature, can be considered a form of violence, defined as "the intentional use of physical force or power, real or threatened, against another person, that results in or has the potential to result in physical or psychological harm" [ 13 , 14 ]. In this regard, understanding the structure of stigma, its harmful consequences, and its identification as a form of violence, science is dedicated to investigating strategies to combat it [ 15 – 17 ]. In 2014, Cook [ 18 ] proposed a multilevel theory to reduce stigma, dividing it into three levels of intervention: structural, interpersonal, and intrapersonal. The structural level addresses conditions, cultural norms, and institutional practices that restrict stigmatized populations' opportunities, resources, and well-being [ 19 ]. Interventions at this level target macrosocial power relations represented by institutions and social discourses, social inequalities, and access to services [ 20 , 21 , 13 ]. At the interpersonal level, interactions between stigmatized and non-stigmatized individuals are considered [ 22 ]. Interventions at this level target relationships between the stigmatized group and the stigmatizing group, known as public stigma, manifested through misinformation, alienation, judgment, and distancing from the stigmatized group, including prejudiced and discriminatory behaviors [ 14 , 20 ]. Lastly, the intrapersonal level focuses on psychological processes resulting from stigma, such as self-concealment and self-stigma, involving the internalization of society's negative opinions about one's group [ 23 , 24 ]. Interventions at this level address the internalization of stereotypes and responses to them, often involving attempts to hide or disguise the stigmatized condition [ 1 , 17 , 20 ]. It is essential to highlight that although the different levels of stigma are categorized separately, they are equally relevant and mutually influence each other causally and reciprocally, reinforcing each other [ 20 ]. This means that interventions at one level can impact other levels and vice versa, underscoring the importance of integrated and comprehensive approaches to address stigma [ 18 ] effectively. Despite advances in research on weight stigma across various fields such as psychology, nutrition, medicine, epidemiology, communication, and media, inconsistencies in the terminologies of its components persist. These discrepancies hinder the understanding of the components of weight stigma and how they interrelate with each other [ 18 , 21 , 25 ]. Furthermore, the imprecise use of different terms can hinder their understanding, proper use, and literature search efforts [ 26 , 27 ]. Considering the importance of accurately naming the components of weight stigma and categorizing their roots and dimensions, the need for a clear and consistent proposal for organizing and associating terminologies and intervention levels becomes evident. Such a proposal would facilitate understanding the different components of weight stigma and guide more effective e ainterventions to combat it at various levels. Thus, the present study aimed to identify components of weight stigma frequently described in the literature and classify them into structural, interpersonal, and intrapersonal intervention levels based on the multilevel theory proposed by Cook et al. (2014) [ 18 ]. Methodology This is a theoretical-methodological study with a quantitative-qualitative approach, conducted from March 2023 to March 2024, and the identification stage of stigma terms related to weight stigma was conducted in March 2023 to maintain the proposal's alignment with current scientific literature. In the first stage of the study, a non-systematic literature review was conducted to identify the most commonly used definitions of weight stigma components. Searches were performed on the Cinahl, Embase, Lilacs, PsycINFO, PubMed, Scielo, Scopus, and Web of Science platforms using keywords such as Obesity, Bias, Prejudice, Weight Stigma, Weight Discrimination, with AND used as the Boolean operator for the search. Subsequently, a proposal was made to classify the components that comprise weight stigma into the different intervention levels proposed by Cook et al. (2014) [ 18 ]. The components were categorized based on their definitions and specificities at each level. At the structural level, components involved in the origins of stigma and affecting many people were included, including cultural institutions and barriers related to education, health, and housing. At the interpersonal level, components relating to interactions within small groups were included, involving individuals with the same stigma or with different stigma statuses. At the intrapersonal level, components related to the individual were included, addressing the stigmatized individual's coping with stigma and the stigmatizer's attitudes and behaviors adopted. The next step involved evaluating the classification proposal by a committee of experts. Ten specialists were invited, and six agreed to participate. All were nutritionists or psychologists, holding master's and/or doctoral degrees in psychology, nutrition, or psychobiology. Their research focused on obesity and/or weight stigma. Participation was voluntary. The experts were invited via email, which included information regarding the study's objectives and procedures. For those who accepted, a brief explanation of the multilevel theory proposed by Cook et al. (2014) [ 18 ] was provided, along with a table of terminologies and the proposal for classifying weight stigma components into levels. For evaluation, experts were asked to indicate whether they deemed the classification proposal "appropriate" or "inappropriate" for each term allocated to respective levels. For instance, "Do you consider it appropriate for the term 'Fatphobia' to be classified under the structural level of weight stigma?" Each item provided space for written justifications and comments. This methodology allowed for a more thorough and substantiated evaluation of the classification proposal. The agreement among experts' judgments on equivalences was assessed using Fleiss' Kappa coefficient (₭). Values of ₭ between 0.40 and 0.60 indicated moderate agreement; between 0.61 and 0.75, good agreement; and above 0.75, excellent agreement [ 28 ]. A five-person research group organized and oversaw this study and the expert evaluations. The first author is a nutritionist, researcher, and graduate student specializing in weight stigma and sexuality. The second, third, and fifth authors are professors, nutritionists, and experienced researchers in the area of obesity, weight stigma, eating behaviors, and body image. The fourth author is a nutritionist. The research group consists of 1 cisgender lesbian white woman, three cisgender heterosexual women, and one cisgender gay man. Regarding weight status, there is one fat woman, one overweight woman, two thin women, and on fat man. Results Based on the literature review conducted in the first stage of the study, ten terms frequently described were identified: Weight Stigma and its nine components (Table 1 ). Out of the ten terms, eight were classified within the figure as derivatives of the original term, such as "Weight Bias," which was included in the classification due to its two components, namely "Implicit Weight Bias" and "Explicit Weight Bias." The classification of weight stigma components into multi-levels was visually organized in Fig. 1 . At the structural level, the components "fatphobia" and "weight-based stereotypes" were included. The components "weight discrimination" and "explicit weight bias" were included at the interpersonal level. Finally, at the intrapersonal level, the components "implicit weight bias" "lipophobia" "fat stigma" and "internalized weight bias" were included. Table 1 Components of weight stigma described in the literature and their respective definitions. Component Definition Weight stigma (12) Refers to social devaluation and denigration of individuals because of their excess body weight, and can lead to negative attitudes, stereotypes, prejudice, and discrimination. Weight -based stereotypes (12) Include generalizations that individuals with overweight or obesity are lazy, gluttonous, lacking in willpower and self-discipline, incompetent, unmotivated to improve their health, non-compliant with medical treatment, and are personally to blame for their higher body weight. Fatphobia (29) Fear of fatness often manifested as negative attitude and stereotypes about fat people Weight discrimination (12) Refers to overt forms of weight-based prejudice and unfair treatment (biased behaviors) toward individuals with overweight or obesity Weight bias (30) Inclination to form unreasonable judgments based on a person's weight. Explicit weight bias (12) Refers to overt, consciously held negative attitudes that can be measured by self-report Implicit weight bias (12) Consists of automatic, negative attributions and stereotypes existing outside of conscious awareness. Lipophobia (31) Generalized aversion to “fat itself”, which can be translated into the person’s own fear of gaining weight. Internalized weight bias (12) It occurs when individuals engage in self-blame and self-directed weight stigma because of their weight. Internalization includes agreeing with stereotypes and applying those stereotypes to oneself and self-devaluation. Fat stigma (32) Fat stigma is the moral discredit or “social death” that people experience because of the negative social meanings attributed to being overweight or obese. The agreements among the expert committee's responses are presented in Table 2 . Components classified under the structural and interpersonal levels had 100% agreement among the experts (₭ = 1.0). There were some disagreements regarding components allocated to the intrapersonal level. The classification of the "fat stigma" component at this level was deemed inappropriate by two experts (₭= 0.4), who argued that they perceive it as a process initiated by others and thus should be classified under the interpersonal level. The classification of the components "lipophobia" and "implicit weight bias" at this level was deemed inappropriate by one expert (₭ = 0.6). This expert considered that "lipophobia" is also structural and that "implicit weight bias" should be allocated alongside "explicit weight bias" at the interpersonal level; however, no justification was provided. Table 2 Relative and absolute frequency of agreement and Fleiss' Kappa among experts on the classification of weight stigma components across structural, interpersonal, and intrapersonal multi-levels. Level Component Agreement among experts ₭ N % Structural Weight -based stereotypes 6 100.0 1.0 Fatphobia 6 100.0 1.0 Interpersonal Weight discrimination 6 100.0 1.0 Explicit weight bias 6 100.0 1.0 Intrapersonal Fat Stigma 4 66.6 0.4 Lipophobia 5 83.3 0.6 Internalized weight bias 6 100.0 1.0 Implicit weight bias 5 83.3 0.6 Discussion This study introduces a novel proposal for a multilevel classification of weight stigma components. It aims to enhance understanding of the weight stigma components identified in the literature and guide interventions at different levels (structural, interpersonal, and intrapersonal). Six of the ten definitions of weight stigma components were taken from the consensus published by Rubino et al., 2020[ 12 ], as it is the first consensus proposing recommendations to end weight stigma. This consensus does not include the terms fatphobia, weight bias, lipophobia, and fat stigma, which were sourced from other references [ 29 – 32 ]. This description of each component's definition is crucial, as it is common in the literature to encounter terms encompassing more than one construct or even blending various concepts [ 13 , 14 ]. Such a situation is problematic because imprecise terminology can hinder understanding and application and make the search for relevant studies more challenging. In healthcare, it is recommended that terms be defined, organized, standardized, and consistently used to enhance information accuracy, efficiency, reliability, and comparability at local, regional, national, and international levels [ 27 ]. Therefore, it is evident that properly distinguishing weight stigma components is necessary, but classifying them according to their roots and dimensions is also essential, as it can make interventions to combat it more effective. Regarding the classification of components across different levels, it is worth noting that these levels are categorizations that reinforce themselves and mutually influence each other. Therefore, some terms may be placed on more than one level, as exemplified by weight stereotypes and fatphobia, which are allocated at the structural level but influence and are influenced by the interpersonal and intrapersonal levels [ 20 , 31 ]. All experts agreed on classifying the term "fatphobia" at the structural level; however, there were considerations regarding the definition provided. Fatphobia was defined as a "Pathological fear of fat manifested as negative attitudes and stereotypes about people with obesity" in Robinson et al.'s work in 1993 when the first fatphobia assessment scale was proposed. It is emphasized that this fear is not individual but a pathological one within an entire society [ 30 ]. Subsequently, Magdalena Piñeyro (2016) defined fatphobia as a system of oppression systematically and structurally reproduced by institutions throughout society that views fatness and overweight as something to be fought against [ 33 ]. Another more recent definition is that fatphobia is "discrimination that leads to social exclusion and, consequently, denies access to fat people. This stigmatization is structural and cultural, transmitted in many diverse spaces and contexts in contemporary society" [ 34 ]. Other authors, even if they did not delve into the definition of fatphobia itself, have discussed its structural place in our society, including a comparison with classism and racism, inherently social constructs in our culture [ 35 ]. Robinson's definition is chosen because it was the first article to delve into the term's definition and construct a scale to measure it, the fatphobia scale. This scale is the only one that measures such a construct and is widely used in research on this topic [ 29 ]. Similarly, the classification of the "weight-based stereotypes" component at the structural level occurred because the term stereotype is considered a cognitive component of an attitude, forming the basis of prejudice towards an individual or group. Lippman, in 1922, defines stereotyping as the simplified process of relating an image to a concept, commonly preconceived. When this relationship becomes familiar and routine, it is associated with a group of people, becoming a generic trait representing that group [ 36 ]. Weight-based stereotypes are responsible for the underrepresentation of fat people in authoritative, academic, sports, social, and positive concept environments, reflecting and perpetuating a structure that views fat individuals as undisciplined, uncontrolled, unattractive, sick, and unhappy, as they are only depicted in such a manner [ 20 , 37 ]. The consequences of fatphobia and weight-based stereotypes are mainly related to limiting access to health promotion resources, housing, health care, education, income, and food [ 38 ]. Jimenez et al. (2023) argue that structural aspects are institutionalized, potentially leading to the death of fat individuals. This was evidenced, for instance, during the COVID-19 pandemic, where fat individuals died due to a lack of adequate equipment to accommodate their bodies [ 39 ]. It is evident, then, that fatphobia and weight-based stereotypes are structural aspects of weight stigma because they are directly related to the root of stigmatization. Interventions at the structural level should focus on reaching as many people as possible and utilize public policies, institutions, legislative actions, mass media, and governmental and/or organizational policies. Inclusive and diversity policies are highly beneficial and should be explored at this level through environmental cues that communicate inclusion, such as larger seats in cinemas, hospital beds that support larger weight capacities, the inclusion of photographs and images of fat individuals in social settings where they are not typically seen, interventions that legally ensure inclusive measures to normalize stigmatized groups. Another recommended measure is hiring professionals from various fields, especially in healthcare, who have larger bodies, to change the stereotype commonly embedded in our culture [ 12 , 18 ]. Due to the evident impact of social media in perpetuating weight stereotypes, interventions should also consider legislative solutions to promote anti-fatphobic policies. Social media platforms should invest in diverse content and moderation teams with dedicated training on weight stigma to reconfigure algorithms towards less stigmatizing pathways [ 20 ]. Harwood et al. (2022) propose that structural interventions targeting weight stigma should include boycotting organizations with discriminatory policies or practices, increasing the presence of stigmatized groups in circles of power and influence, educating managers and frontline personnel, existing legislation to protect these rights, and introducing regulatory requirements for organizations to meet equality goals [ 40 ]. At the interpersonal level, experts unanimously considered the classification of the terms "weight discrimination" and "explicit weight bias" adequate. 'It is evident from the definition of the components that discriminatory actions are carried out by and between people", as one expert stated. Discrimination is defined as [...] a type of behavioral response to stigma and prejudice, defined as negative attitudes towards the value of specific social groups, or as an effective form of stigma or prejudice, [and thus, constituting a] clear distinction between ideas, attitudes or ideologies, and their behavioral consequences in discriminatory actions [ 41 ]. Discrimination thus involves individuals from a particular social group excluding another group with different characteristics from theirs from a power relationship, attributing lower moral value characteristics to them while assuming that members of the dominant groups possess virtuous characteristics that others lack. Weight discrimination follows a similar path, as individuals with larger bodies are frequently discriminated against, and such discriminatory behaviors increase as BMI increases Such interpersonal behavior commonly occurs subtly and includes family members, friends, school/college peers/academic environments in general, vendors, doctors, and healthcare professionals [ 44 – 47 ]. The main consequences of discrimination can be highlighted in the realm of health, ranging from increased risk of psychological health problems, for example (depression and substance use) to physiological conditions such as diabetes, myocardial infarction, and increased weight gain [ 48 , 49 , 50 ]. Some authors argue that there is a direct cause-and-effect relationship between weight discrimination and the maintenance or increase of obesity [ 51 – 53 ]. The concern about the consequences of weight discrimination is the same when we delve into understanding the concept and consequences of explicit weight bias, which, like discrimination, can be subtle but has explicit and evident characteristics. Such discrimination is prevalent among healthcare professionals and can be perceived even when the patient's concerns are unrelated to their body weight. Previous studies showed that healthcare professionals (physicians, nurses, dietitians, psychologists, physical education professionals) frequently offer unsolicited advice and treatments for weight loss, engage in differential treatment by refusing to perform specific tests, spend less time in consultation with individuals with higher weight, display negative facial expressions, make less eye contact, and often doubt complaints and reports of eating habits and healthy lifestyles from individuals with higher weight [ 54 – 63 ]. A recent systematic review analyzed 41 studies involving students and healthcare professionals regarding weight stigma and identified that implicit and explicit weight bias is naturalized within this population [ 64 ]. Therefore, to combat the components of weight stigma at the interpersonal level, academic interventions are needed to raise awareness among student groups on the topic, promote workshops and lectures with healthcare professionals to improve communication between stigmatizing and stigmatized groups, and also support groups affirming the values of stigmatized groups, such as engagement with activism [ 18 ]. Fat activism emerged in the United States, heavily influenced by feminist theories in the 1960s, with the primary goal of advocating for the rights of fat people, challenging negative and stigmatizing ideas about fat bodies, and encouraging acceptance of people's differences [ 65 ]. Lee and colleagues (2014) evaluated the impact of interventions on beliefs about obesity and discriminatory attitudes, finding small yet positive results [ 66 ]. Another review conducted by Paolis et al. (2023) demonstrated that educational interventions with healthcare professionals effectively reduced explicit weight bias and that reflective interventions sensitized participants to their prejudice and discriminatory attitudes. These findings suggest the importance of intervening simultaneously across different levels [ 67 ]. At the intrapersonal level, the terms implicit weight bias, internalized weight stigma, lipophobia, and fat stigma were classified. All experts agreed with the classification, with only one mentioning that lipophobia could be at the structural level and that the term implicit weight bias could be at the interpersonal level. Here, it is worth highlighting that classifying a term at a given level only considers its origin but clarifies how the levels are affected and mutually interrelated in a bidirectional way (18) , hence the choice to keep them at the intrapersonal level, corroborating most experts. Unlike explicit bias, implicit weight bias is at the unconscious level of the stigmatizing individual. A study carried out in 2020 showed that in cities with a higher prevalence of obesity, the implicit weight bias is lower. In cities with a lower prevalence of fat bodies, there is a more significant internalized weight bias [ 69 ]. The hypothesis raised by the authors is that where there is less presence of larger bodies, there is a hostile treatment and environment for such bodies since this inner cognitive aspect of people is a predictor of discriminatory processes. The consequences for the stigmatized group are worse health markers related to chronic psychosocial stress when compared to the results referring to explicit weight bias [ 68 ]. Internalized weight stigma is associated with poorer quality of life indicators among stigmatized individuals, as they tend to internalize societal concepts about themselves, leading to feelings of incompetence, self-hatred, or devaluation [ 70 ]. Lipophobia is a rarely used term that refers to a fear of becoming fat, particularly in a society where fatness carries such negative connotations. Individuals experiencing lipophobia commonly struggle with the conflict between being seen as beautiful and accepted versus being viewed as ugly and rejected. This is because the process of pathologizing fatness has associated it with ugliness and illness, as mentioned earlier [ 71 ]. Fat stigma refers to an individual experience of the stigmatized individual, which begins with the "social death" of the individual due to their body weight. Psychological and mental outcomes are worse in those individuals who suffer from this "social death" and contribute to the development, maintenance, and worsening of low self-esteem, depression, anxiety, concerns about body image, and binge eating [ 32 ]. Interventions at this level should include affirming positive values for the stigmatized group and enhancing their self-efficacy and sense of belonging. It is also important to emphasize that interventions at this level exemplify the multidimensionality and bifactorial nature of the model, as they may involve interventions with stigmatizing groups akin to interpersonal-level interventions. Recommendations for interventions with stigmatizing groups also contribute to addressing aspects of stigma at the interpersonal level by broadening cultural understanding among individuals [ 18 ]. Evidence in the literature indicates that educational approaches (combined across levels) have been effective in reducing stigma related to mental illnesses [ 18 , 72 ]. Third-wave behavioral therapies based on mindfulness are promising tools for intrapersonal interventions. In this approach, the target for change is not the content, intensity, or frequency of the thoughts themselves but rather the context, function, and manner of relating to them, thereby improving the ability to respond to self-stigmatizing thoughts [ 73 ]. A study aimed at determining the efficacy of mindfulness-based approaches in addressing self-stigma and shame showed positive outcomes, such as increased self-compassion and shame reduction. Additionally, it is a technique that positively impacts quality of life and aspects of psychological health [ 74 ]. The potential of our study lies in being the first, to our knowledge, to delve into analyzing the components that constitute weight stigma, aiming to classify them according to their origins and how they interrelate and mutually influence each other. This study is highly relevant in aiding efforts to combat stigma, offering a clear and precise approach based on understanding this categorization. As for the study's limitations, we can mention the relatively small number of expert analyses. However, the analyses received were comprehensive, supported by theoretical and scientific foundations, and provided by professionals with substantial experience and significance in research. Conclusion We presented a comprehensive multi-level classification of weight stigma components, as follows: Fatphobia and weight-based stereotypes at the structural level; weight discrimination and explicit weight bias at the interpersonal level, and implicit weight bias, internalized weight stigma, lipophobia, and fat stigma at the intrapersonal level. It is emphasized that there is a bidirectional relationship between these levels, and recent evidence highlights the importance of multi-level stigma-reducing interventions. In future studies, this classification can help assess the association between inter- and intra-level components of weight stigma and guide interventions across different levels, specifying the component that is the focus of the intervention. This approach aims to facilitate organized knowledge construction that is intelligible for researchers, healthcare professionals, and society. Declarations Ethics approval and consent to participate: Research approved by the ethics and research committee of the Clinics Hospital of Ribeirão Preto of the University of São Paulo. Protocol: 43226821.6.0000.5440 Funding: This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Brasil (CAPES) - Finance Code 001 and by the Universidade de Ribeirão Preto – UNAERP. Author Contribution Authors' contributions and e-mailsGCA de S has contributed to the conception and design of the work, the acquisition, analysis, and interpretation of data, and has drafted the work. ( [email protected] )MFL has contributed to the conception and design of the work, the acquisition, analysis, and interpretation of data, and has drafted the work. ( [email protected] )FROP has contributed to the acquisition, analysis, and interpretation of data. ( [email protected] )LB dos S has contributed to data acquisition, analysis, and interpretation. ( [email protected] ) CCJ has contributed to the conception and design of the work, the acquisition, analysis, and interpretation of data, and has drafted the work. ( [email protected] )All authors read and approved the final manuscript. Acknowledgement We acknowledge the committee of experts for their voluntary and competent participation in this study. References Goffman E. Stigma; Notes on the Management of Spoiled Identity. Englewood Cliffs, N.J.: Prentice-Hall; 1963. Link BG, Phelan JC. Conceptualizing Stigma. Annual Review of Sociology [Internet]. 2001;27(1):363–85. https://www.annualreviews.org/content/journals/10.1146/annurev.soc.27.1.3633 . Haslam D. Obesity: a medical history. Obes Rev. 2007;8(s1):316. 10.1111/j.1467-789X.2007.00314.x . Eknoyan G. A history of obesity, or how what was good became ugly and then bad. Adv Chronic Kidney Dis. 2006;13(4):421–7. 10.1053/j.ackd.2006.07.002 . Santolin CB. 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Obesity research [Internet]. 2003;11(10):1168–77. https://www.ncbi.nlm.nih.gov/pubmed/14569041 . Elboim-Gabyzon M, Attar K, Peleg S. Weight Stigmatization among Physical Therapy Students and Registered Physical Therapists. Obes Facts. 2020;13(2):1–13. 10.1159/000504809 . Jayawickrama RS, O'Connor M, Flint SW, Hemmingsson E, Lawrence BJ. Explicit and implicit weight bias among health care students: a cross-sectional study of 39 Australian universities. EClinicalMedicine. 2023;58:101894. 10.1016/j.eclinm.2023.101894 . Tanneberger A, Ciupitu-Plath C. Nurses’ Weight Bias in Caring for Obese Patients: Do Weight Controllability Beliefs Influence the Provision of Care to Obese Patients? Clin Nurs Res. 2018;27(4):414–32. 10.1177/1054773816687443 . Chambliss HO, Finley CE, Blair SN. Attitudes toward Obese Individuals among Exercise Science Students. Med Sci Sports Exerc. 2004;36(3):468–74. 10.1249/01.mss.0000117115.94062.e4 . Obara AA, Vivolo SRGF, Alvarenga M. dos S. Weight bias in nutritional practice: a study with nutrition students. Cadernos de Saúde Pública [Internet]. 2018;34:e00088017. https://www.scielo.br/j/csp/a/YkFF7RGTnDP8kQmCHzk5sBS/?lang=en . Swift JA, Hanlon S, El-Redy L, Puhl RM, Glazebrook C. Weight bias among UK trainee dietitians, doctors, nurses and nutritionists. J Hum Nutr Dietetics. 2012;26(4):395–402. 10.1111/jhn.12019 . Sikorski C, Luppa M, Glaesmer H, Brähler E, König HH, Riedel-Heller SG. Attitudes of Health Care Professionals towards Female Obese Patients. Obesity Facts [Internet]. 2013 [cited 2019 Dec 1];6(6):512–22. https://www.karger.com/Article/FullText/356692 . Poon MY, Tarrant M. Obesity: attitudes of undergraduate student nurses and registered nurses. J Clin Nurs. 2009;18(16):2355–65. Yılmaz HÖ, Yabancı Ayhan N. Is there prejudice against obese persons among health professionals? A sample of student nurses and registered nurses. Perspect Psychiatr Care. 2019;55(2):262–8. Lawrence BJ, Kerr D, Pollard CM, Theophilus M, Alexander E, Haywood D, O'Connor M. Weight bias among health care professionals: A systematic review and meta-analysis. Obes (Silver Spring). 2021;29(11):1802–12. 10.1002/oby.23266 . Paim MB, Kovaleski DF, Selau BL. Compreendendo o termo gordofobia médica a partir da perspectiva de pessoas gordas. Saúde Soc. 2024;33(1). https://doi.org/10.1590/S0104-12902024220842pt . Lee M, Ata RN, Brannick MT. The malleability of weight-biased attitudes and beliefs: a meta-analysis of weight bias reduction interventions. Body Image. 2014;11(3):251–9. 10.1016/j.bodyim.2014.03.003 . De Paolis M, Culverhouse S, Kunaratnam K. Reducing weight bias and stigma in health and fitness professionals: a scoping review of intervention studies. Proc Nutr Soc. 2023;82(OCE2). 10.1017/S0029665123001490 . Cullin JM. Implicit and explicit fat bias among adolescents from two U.S. populations varying by obesity prevalence. Pediatr Obes. 2021;16(5). 10.1111/ijpo.12747 . Puhl RM, Lessard LM, Pearl RL, Himmelstein MS, Foster GD. International comparisons of weight stigma: addressing a void in the field. Int J Obes (Lond). 2021;45(9):1976–85. 10.1038/s41366-021-00860-z . Latner JD, Durso LE, Mond JM. Health and health-related quality of life among treatment-seeking overweight and obese adults: associations with internalized weight bias. J Eat Disord. 2013;1:3. https://doi.org/10.1186/2050-2974-1-3 . Francisco LV, Diez-Garcia RW, ABORDAGEM TERAPÊUTICA DA, OBESIDADE: ENTRE CONCEITOS E PRECONCEITOS. Demetra: Aliment Nutr Saude. 2015;10(3):705–716. https://doi.org/10.12957/demetra.2015.16095 . Corrigan PW, Morris SB, Michaels PJ, Rafacz JD, Rüsch N. Challenging the Public Stigma of Mental Illness: A Meta-Analysis of Outcome Studies. Psychiatric Services [Internet]. 2012;63(10):963–73. https://pubmed.ncbi.nlm.nih.gov/23032675/ . Hayes SC, Villatte M, Levin M, Hildebrandt M. Open, Aware, and Active: Contextual Approaches as an Emerging Trend in the Behavioral and Cognitive Therapies. Ann Rev Clin Psychol. 2011;7(1):141–68. Stynes G, Leão CS, McHugh L. Exploring the effectiveness of mindfulness-based and third wave interventions in addressing self-stigma, shame and their impacts on psychosocial functioning: A systematic review. J Contextual Behav Sci. 2022;23:174–89. https://doi.org/10.1016/j.jcbs.2022.01.006 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4660605","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":331468886,"identity":"884d708d-289a-460f-b686-6394ffd222c3","order_by":0,"name":"Gabriela Cristina Arces de Souza","email":"","orcid":"","institution":"Universidade de São Paulo","correspondingAuthor":false,"prefix":"","firstName":"Gabriela","middleName":"Cristina Arces","lastName":"de Souza","suffix":""},{"id":331468889,"identity":"555cb263-8b47-4d53-92f1-1285c45fbacc","order_by":1,"name":"Maria Fernanda Laus","email":"","orcid":"","institution":"Universidade de Ribeirão Preto","correspondingAuthor":false,"prefix":"","firstName":"Maria","middleName":"Fernanda","lastName":"Laus","suffix":""},{"id":331468890,"identity":"6f174a97-7943-4ee3-88c4-060fef3f518f","order_by":2,"name":"Fernanda Rodrigues de Oliveira Penaforte","email":"","orcid":"","institution":"Federal University of Triângulo Mineiro","correspondingAuthor":false,"prefix":"","firstName":"Fernanda","middleName":"Rodrigues de Oliveira","lastName":"Penaforte","suffix":""},{"id":331468891,"identity":"14de5aa9-22be-48c3-b8b1-3c922e082ca7","order_by":3,"name":"Lucas Brandão dos Santos","email":"","orcid":"","institution":"Universidade de São Paulo","correspondingAuthor":false,"prefix":"","firstName":"Lucas","middleName":"Brandão dos","lastName":"Santos","suffix":""},{"id":331468893,"identity":"811b3fa0-97fa-4fb3-99f8-c7015991ddcf","order_by":4,"name":"Camila Cremonezi Japur","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA1UlEQVRIiWNgGAWjYJCCAw8Y2EA04wMQaUCUlgSIFmYDorUwJEAoNgmitPC3n048kFDDJ28ukfusmufPHQZz6QP4tUicyd1wIOEYm+HOGelmt3nbnjFY9iXg12LAANLCxsa44UYa223ehsMMBmcIOMyA/y1Qyz82e5CWYp4/xGiRANqS2MaWCNLCzMNGhBaJG0BbEvvYknf2PGOWnNv2jMeyh4AW/v7czR8+fDtmu509jfHDmz935Mx5CGiBgmOw6DhApAYGhhq4FmJ1jIJRMApGwQgCAB6URxYPvk2EAAAAAElFTkSuQmCC","orcid":"","institution":"Universidade de São Paulo","correspondingAuthor":true,"prefix":"","firstName":"Camila","middleName":"Cremonezi","lastName":"Japur","suffix":""}],"badges":[],"createdAt":"2024-06-29 21:08:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4660605/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4660605/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":61343019,"identity":"8fb1502b-8587-48db-9d0c-d2f31efb78d6","added_by":"auto","created_at":"2024-07-29 17:16:21","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1339736,"visible":true,"origin":"","legend":"\u003cp\u003eClassification of Weight Stigma Components into Multi-levels\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4660605/v1/0896da55d88004e112e93356.jpg"},{"id":70714054,"identity":"f356074d-58fd-45fb-88ea-7712d7a5b9bd","added_by":"auto","created_at":"2024-12-06 01:08:57","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1792404,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4660605/v1/1962747a-f83d-48fd-b474-b85021b073ab.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"End of Weight Stigma: A Proposal for a Multilevel Classification of its Components for Intervention Purposes","fulltext":[{"header":"Plain English Summary","content":"\u003cp\u003eWeight stigma has various components, and this study aimed to classify them across multiple intervention levels. The intervention levels are as follows: structural\u0026mdash;components involved in the origin of stigma; interpersonal\u0026mdash;components about interactions within small groups; and intrapersonal\u0026mdash;components related to the individual.\u003c/p\u003e\n\u003cp\u003eThese components of weight stigma were compiled from a review of the scientific literature and classified into levels. This classification was submitted to a committee of experts on the subject. Expert consensus on the classification of terms was evaluated, and the final proposal was discussed.\u003c/p\u003e\n\u003cp\u003eTen terms were identified, and eight of them were classified as follows: at the structural level, \u0026quot;fatphobia\u0026quot; and \u0026quot;weight-based stereotypes\u0026quot;; at the interpersonal level, \u0026quot;weight discrimination\u0026quot; and \u0026quot;explicit weight bias\u0026quot;; and at the intrapersonal level, \u0026quot;implicit weight bias\u0026quot; \u0026quot;lipophobia\u0026quot; \u0026quot;fat stigma\u0026quot; and \u0026quot;internalized weight bias\u0026quot;.\u003c/p\u003e\n\u003cp\u003eThere was complete agreement at the structural and interpersonal levels. At the intrapersonal level, there were disagreements regarding the classification of \u0026quot;fat stigma\u0026quot; \u0026quot;lipophobia\u0026quot; and \u0026quot;implicit weight bias\u0026quot; which one expert considered inappropriate. After evaluating and considering these perspectives, the classification remained unchanged.\u003c/p\u003e\n\u003cp\u003eIt is emphasized that there is a direct and bidirectional relationship between these levels, and this study may contribute to more targeted and effective interventions to combat weight stigma.\u003c/p\u003e"},{"header":"Background","content":"\u003cp\u003eAs defined by Goffman [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], the stigma refers to an attribute that profoundly discredits its bearer, leading it to be seen as contaminated and scorned. Link \u0026amp; Phelan (2001) [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] further expanded this definition, describing stigma as a process of five interrelated components. First, there is labeling, where human differences are identified and labeled. Next comes labeling, in which these labels are associated with characteristics deemed undesirable by dominant cultural beliefs. This leads to separation, where labeled individuals become distinct from those who do not possess these undesirable characteristics. This differentiation results in the loss of status in society as stigmatized individuals begin to face discrimination. When these five components \u0026minus;\u0026thinsp;(1) labeling, (2) negative attributes, (3) separation, (4) status loss, and (5) discrimination - unfold in this sequence, they converge to construct stigma [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe history of weight stigma is complex, and here, we will provide a brief contextualization to understand the topic's relevance. Initially associated with health and prosperity [3.4], body fat began to be blamed during the Classical era. This shift marked the beginning of labeling and stigmatizing fat bodies as undesirable [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. From then on, beliefs and attitudes towards fat bodies started to change, intensifying the process of stigmatization. In the 19th century, Adolphe Quetelet sought to define the characteristics of the \"average man\" and developed the Quetelet index, later known as Body Mass Index (BMI), which is now used worldwide as a diagnostic criterion for obesity. In 1948, obesity was included in the International Classification of Diseases, reinforcing the pathologization of fat. However, there was no clinical evidence of a causal relationship between excess weight and associated comorbidities at that time. In 1998, the World Health Organization promoted BMI as a diagnostic and classification parameter for obesity [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFurthermore, psychology has played a significant role in this process by associating the fat body with overeating, depression, hypochondria, and melancholy, reinforcing the pathologization of fat since the 17th century and amplifying it with the advent of Freudian thought in the 1940s. This process further deepened the stigma associated with fat [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], which solidified over time.\u003c/p\u003e \u003cp\u003eIn this direction, fat ceases to be merely a physical characteristic and comes to be seen as a consequence of undisciplined behaviors, culminating in an unwanted physical identity. This process involved distinction, labeling, and loss of status [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Later, excess weight is characterized as a physiological disorder or disease, systematically pathologized and institutionalized as a medical issue [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Consequently, the fat body is arbitrarily and automatically elevated to the status of a diseased body [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Notably, this process co-occurred with the idealization of thinness, as described by Claude Fischler, who depicts an \"almost manic rejection of obesity\" [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe process of weight-related stigma itself entails various consequences for overweight individuals, including increased depression, anxiety, social isolation, and eating disorders; higher likelihood of developing dementia; elevated suicide rates; greater tendency towards sedentary behavior; metabolic changes; and avoidance of healthcare, including emergency services [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eGiven the significantly negative impact on the individual, the process of stigmatization, of any nature, can be considered a form of violence, defined as \"the intentional use of physical force or power, real or threatened, against another person, that results in or has the potential to result in physical or psychological harm\" [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. In this regard, understanding the structure of stigma, its harmful consequences, and its identification as a form of violence, science is dedicated to investigating strategies to combat it [\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn 2014, Cook [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] proposed a multilevel theory to reduce stigma, dividing it into three levels of intervention: structural, interpersonal, and intrapersonal. The structural level addresses conditions, cultural norms, and institutional practices that restrict stigmatized populations' opportunities, resources, and well-being [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Interventions at this level target macrosocial power relations represented by institutions and social discourses, social inequalities, and access to services [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAt the interpersonal level, interactions between stigmatized and non-stigmatized individuals are considered [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Interventions at this level target relationships between the stigmatized group and the stigmatizing group, known as public stigma, manifested through misinformation, alienation, judgment, and distancing from the stigmatized group, including prejudiced and discriminatory behaviors [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Lastly, the intrapersonal level focuses on psychological processes resulting from stigma, such as self-concealment and self-stigma, involving the internalization of society's negative opinions about one's group [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Interventions at this level address the internalization of stereotypes and responses to them, often involving attempts to hide or disguise the stigmatized condition [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIt is essential to highlight that although the different levels of stigma are categorized separately, they are equally relevant and mutually influence each other causally and reciprocally, reinforcing each other [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. This means that interventions at one level can impact other levels and vice versa, underscoring the importance of integrated and comprehensive approaches to address stigma [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] effectively.\u003c/p\u003e \u003cp\u003eDespite advances in research on weight stigma across various fields such as psychology, nutrition, medicine, epidemiology, communication, and media, inconsistencies in the terminologies of its components persist. These discrepancies hinder the understanding of the components of weight stigma and how they interrelate with each other [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Furthermore, the imprecise use of different terms can hinder their understanding, proper use, and literature search efforts [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eConsidering the importance of accurately naming the components of weight stigma and categorizing their roots and dimensions, the need for a clear and consistent proposal for organizing and associating terminologies and intervention levels becomes evident. Such a proposal would facilitate understanding the different components of weight stigma and guide more effective e ainterventions to combat it at various levels. Thus, the present study aimed to identify components of weight stigma frequently described in the literature and classify them into structural, interpersonal, and intrapersonal intervention levels based on the multilevel theory proposed by Cook et al. (2014) [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e"},{"header":"Methodology","content":"\u003cp\u003eThis is a theoretical-methodological study with a quantitative-qualitative approach, conducted from March 2023 to March 2024, and the identification stage of stigma terms related to weight stigma was conducted in March 2023 to maintain the proposal's alignment with current scientific literature. In the first stage of the study, a non-systematic literature review was conducted to identify the most commonly used definitions of weight stigma components. Searches were performed on the Cinahl, Embase, Lilacs, PsycINFO, PubMed, Scielo, Scopus, and Web of Science platforms using keywords such as Obesity, Bias, Prejudice, Weight Stigma, Weight Discrimination, with AND used as the Boolean operator for the search.\u003c/p\u003e \u003cp\u003eSubsequently, a proposal was made to classify the components that comprise weight stigma into the different intervention levels proposed by Cook et al. (2014) [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The components were categorized based on their definitions and specificities at each level. At the structural level, components involved in the origins of stigma and affecting many people were included, including cultural institutions and barriers related to education, health, and housing. At the interpersonal level, components relating to interactions within small groups were included, involving individuals with the same stigma or with different stigma statuses. At the intrapersonal level, components related to the individual were included, addressing the stigmatized individual's coping with stigma and the stigmatizer's attitudes and behaviors adopted.\u003c/p\u003e \u003cp\u003eThe next step involved evaluating the classification proposal by a committee of experts. Ten specialists were invited, and six agreed to participate. All were nutritionists or psychologists, holding master's and/or doctoral degrees in psychology, nutrition, or psychobiology. Their research focused on obesity and/or weight stigma. Participation was voluntary.\u003c/p\u003e \u003cp\u003eThe experts were invited via email, which included information regarding the study's objectives and procedures. For those who accepted, a brief explanation of the multilevel theory proposed by Cook et al. (2014) [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] was provided, along with a table of terminologies and the proposal for classifying weight stigma components into levels. For evaluation, experts were asked to indicate whether they deemed the classification proposal \"appropriate\" or \"inappropriate\" for each term allocated to respective levels. For instance, \"Do you consider it appropriate for the term 'Fatphobia' to be classified under the structural level of weight stigma?\" Each item provided space for written justifications and comments. This methodology allowed for a more thorough and substantiated evaluation of the classification proposal.\u003c/p\u003e \u003cp\u003eThe agreement among experts' judgments on equivalences was assessed using Fleiss' Kappa coefficient (₭). Values of ₭ between 0.40 and 0.60 indicated moderate agreement; between 0.61 and 0.75, good agreement; and above 0.75, excellent agreement [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA five-person research group organized and oversaw this study and the expert evaluations. The first author is a nutritionist, researcher, and graduate student specializing in weight stigma and sexuality. The second, third, and fifth authors are professors, nutritionists, and experienced researchers in the area of obesity, weight stigma, eating behaviors, and body image. The fourth author is a nutritionist. The research group consists of 1 cisgender lesbian white woman, three cisgender heterosexual women, and one cisgender gay man. Regarding weight status, there is one fat woman, one overweight woman, two thin women, and on fat man.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eBased on the literature review conducted in the first stage of the study, ten terms frequently described were identified: Weight Stigma and its nine components (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Out of the ten terms, eight were classified within the figure as derivatives of the original term, such as \"Weight Bias,\" which was included in the classification due to its two components, namely \"Implicit Weight Bias\" and \"Explicit Weight Bias.\" The classification of weight stigma components into multi-levels was visually organized in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. At the structural level, the components \"fatphobia\" and \"weight-based stereotypes\" were included. The components \"weight discrimination\" and \"explicit weight bias\" were included at the interpersonal level. Finally, at the intrapersonal level, the components \"implicit weight bias\" \"lipophobia\" \"fat stigma\" and \"internalized weight bias\" were included.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComponents of weight stigma described in the literature and their respective definitions.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComponent\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDefinition\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeight stigma \u003csup\u003e(12)\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRefers to social devaluation and denigration of individuals because of their excess body weight, and can lead to negative attitudes, stereotypes, prejudice, and discrimination.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeight -based stereotypes \u003csup\u003e(12)\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInclude generalizations that individuals with overweight or obesity are lazy, gluttonous, lacking in willpower and self-discipline, incompetent, unmotivated to improve their health, non-compliant with medical treatment, and are personally to blame for their higher body weight.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFatphobia \u003csup\u003e(29)\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFear of fatness often manifested as negative attitude and stereotypes about fat people\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeight discrimination \u003csup\u003e(12)\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRefers to overt forms of weight-based prejudice and unfair treatment (biased behaviors) toward individuals with overweight or obesity\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeight bias \u003csup\u003e(30)\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInclination to form unreasonable judgments based on a person's weight.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExplicit weight bias \u003csup\u003e(12)\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRefers to overt, consciously held negative attitudes that can be measured by self-report\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImplicit weight bias \u003csup\u003e(12)\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConsists of automatic, negative attributions and stereotypes existing outside of conscious awareness.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLipophobia \u003csup\u003e(31)\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGeneralized aversion to \u0026ldquo;fat itself\u0026rdquo;, which can be translated into the person\u0026rsquo;s own fear of gaining weight.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInternalized weight bias \u003csup\u003e(12)\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIt occurs when individuals engage in self-blame and self-directed weight stigma because of their weight. Internalization includes agreeing with stereotypes and applying those stereotypes to oneself and self-devaluation.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFat stigma \u003csup\u003e(32)\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFat stigma is the moral discredit or \u0026ldquo;social death\u0026rdquo; that people experience because of the negative social meanings attributed to being overweight or obese.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe agreements among the expert committee's responses are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Components classified under the structural and interpersonal levels had 100% agreement among the experts (₭ = 1.0). There were some disagreements regarding components allocated to the intrapersonal level. The classification of the \"fat stigma\" component at this level was deemed inappropriate by two experts (₭= 0.4), who argued that they perceive it as a process initiated by others and thus should be classified under the interpersonal level. The classification of the components \"lipophobia\" and \"implicit weight bias\" at this level was deemed inappropriate by one expert (₭ = 0.6). This expert considered that \"lipophobia\" is also structural and that \"implicit weight bias\" should be allocated alongside \"explicit weight bias\" at the interpersonal level; however, no justification was provided.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRelative and absolute frequency of agreement and Fleiss' Kappa among experts on the classification of weight stigma components across structural, interpersonal, and intrapersonal multi-levels.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eLevel\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eComponent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eAgreement among experts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e₭\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eStructural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWeight -based stereotypes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFatphobia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eInterpersonal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWeight discrimination\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExplicit weight bias\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eIntrapersonal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFat Stigma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e66.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLipophobia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e83.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInternalized weight bias\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eImplicit weight bias\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e83.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study introduces a novel proposal for a multilevel classification of weight stigma components. It aims to enhance understanding of the weight stigma components identified in the literature and guide interventions at different levels (structural, interpersonal, and intrapersonal).\u003c/p\u003e \u003cp\u003eSix of the ten definitions of weight stigma components were taken from the consensus published by Rubino et al., 2020[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], as it is the first consensus proposing recommendations to end weight stigma. This consensus does not include the terms fatphobia, weight bias, lipophobia, and fat stigma, which were sourced from other references [\u003cspan additionalcitationids=\"CR30 CR31\" citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis description of each component's definition is crucial, as it is common in the literature to encounter terms encompassing more than one construct or even blending various concepts [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Such a situation is problematic because imprecise terminology can hinder understanding and application and make the search for relevant studies more challenging.\u003c/p\u003e \u003cp\u003eIn healthcare, it is recommended that terms be defined, organized, standardized, and consistently used to enhance information accuracy, efficiency, reliability, and comparability at local, regional, national, and international levels [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Therefore, it is evident that properly distinguishing weight stigma components is necessary, but classifying them according to their roots and dimensions is also essential, as it can make interventions to combat it more effective.\u003c/p\u003e \u003cp\u003eRegarding the classification of components across different levels, it is worth noting that these levels are categorizations that reinforce themselves and mutually influence each other. Therefore, some terms may be placed on more than one level, as exemplified by weight stereotypes and fatphobia, which are allocated at the structural level but influence and are influenced by the interpersonal and intrapersonal levels [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAll experts agreed on classifying the term \"fatphobia\" at the structural level; however, there were considerations regarding the definition provided. Fatphobia was defined as a \"Pathological fear of fat manifested as negative attitudes and stereotypes about people with obesity\" in Robinson et al.'s work in 1993 when the first fatphobia assessment scale was proposed. It is emphasized that this fear is not individual but a pathological one within an entire society [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Subsequently, Magdalena Pi\u0026ntilde;eyro (2016) defined fatphobia as a system of oppression systematically and structurally reproduced by institutions throughout society that views fatness and overweight as something to be fought against [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAnother more recent definition is that fatphobia is \"discrimination that leads to social exclusion and, consequently, denies access to fat people. This stigmatization is structural and cultural, transmitted in many diverse spaces and contexts in contemporary society\" [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Other authors, even if they did not delve into the definition of fatphobia itself, have discussed its structural place in our society, including a comparison with classism and racism, inherently social constructs in our culture [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRobinson's definition is chosen because it was the first article to delve into the term's definition and construct a scale to measure it, the fatphobia scale. This scale is the only one that measures such a construct and is widely used in research on this topic [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSimilarly, the classification of the \"weight-based stereotypes\" component at the structural level occurred because the term stereotype is considered a cognitive component of an attitude, forming the basis of prejudice towards an individual or group. Lippman, in 1922, defines stereotyping as the simplified process of relating an image to a concept, commonly preconceived. When this relationship becomes familiar and routine, it is associated with a group of people, becoming a generic trait representing that group [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWeight-based stereotypes are responsible for the underrepresentation of fat people in authoritative, academic, sports, social, and positive concept environments, reflecting and perpetuating a structure that views fat individuals as undisciplined, uncontrolled, unattractive, sick, and unhappy, as they are only depicted in such a manner [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe consequences of fatphobia and weight-based stereotypes are mainly related to limiting access to health promotion resources, housing, health care, education, income, and food [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Jimenez et al. (2023) argue that structural aspects are institutionalized, potentially leading to the death of fat individuals. This was evidenced, for instance, during the COVID-19 pandemic, where fat individuals died due to a lack of adequate equipment to accommodate their bodies [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIt is evident, then, that fatphobia and weight-based stereotypes are structural aspects of weight stigma because they are directly related to the root of stigmatization. Interventions at the structural level should focus on reaching as many people as possible and utilize public policies, institutions, legislative actions, mass media, and governmental and/or organizational policies. Inclusive and diversity policies are highly beneficial and should be explored at this level through environmental cues that communicate inclusion, such as larger seats in cinemas, hospital beds that support larger weight capacities, the inclusion of photographs and images of fat individuals in social settings where they are not typically seen, interventions that legally ensure inclusive measures to normalize stigmatized groups. Another recommended measure is hiring professionals from various fields, especially in healthcare, who have larger bodies, to change the stereotype commonly embedded in our culture [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDue to the evident impact of social media in perpetuating weight stereotypes, interventions should also consider legislative solutions to promote anti-fatphobic policies. Social media platforms should invest in diverse content and moderation teams with dedicated training on weight stigma to reconfigure algorithms towards less stigmatizing pathways [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHarwood et al. (2022) propose that structural interventions targeting weight stigma should include boycotting organizations with discriminatory policies or practices, increasing the presence of stigmatized groups in circles of power and influence, educating managers and frontline personnel, existing legislation to protect these rights, and introducing regulatory requirements for organizations to meet equality goals [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAt the interpersonal level, experts unanimously considered the classification of the terms \"weight discrimination\" and \"explicit weight bias\" adequate. 'It is evident from the definition of the components that discriminatory actions are carried out by and between people\", as one expert stated. Discrimination is defined as [...] a type of behavioral response to stigma and prejudice, defined as negative attitudes towards the value of specific social groups, or as an effective form of stigma or prejudice, [and thus, constituting a] clear distinction between ideas, attitudes or ideologies, and their behavioral consequences in discriminatory actions [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDiscrimination thus involves individuals from a particular social group excluding another group with different characteristics from theirs from a power relationship, attributing lower moral value characteristics to them while assuming that members of the dominant groups possess virtuous characteristics that others lack. Weight discrimination follows a similar path, as individuals with larger bodies are frequently discriminated against, and such discriminatory behaviors increase as BMI increases\u003c/p\u003e \u003cp\u003eSuch interpersonal behavior commonly occurs subtly and includes family members, friends, school/college peers/academic environments in general, vendors, doctors, and healthcare professionals [\u003cspan additionalcitationids=\"CR45 CR46\" citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. The main consequences of discrimination can be highlighted in the realm of health, ranging from increased risk of psychological health problems, for example (depression and substance use) to physiological conditions such as diabetes, myocardial infarction, and increased weight gain [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. Some authors argue that there is a direct cause-and-effect relationship between weight discrimination and the maintenance or increase of obesity [\u003cspan additionalcitationids=\"CR52\" citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe concern about the consequences of weight discrimination is the same when we delve into understanding the concept and consequences of explicit weight bias, which, like discrimination, can be subtle but has explicit and evident characteristics. Such discrimination is prevalent among healthcare professionals and can be perceived even when the patient's concerns are unrelated to their body weight. Previous studies showed that healthcare professionals (physicians, nurses, dietitians, psychologists, physical education professionals) frequently offer unsolicited advice and treatments for weight loss, engage in differential treatment by refusing to perform specific tests, spend less time in consultation with individuals with higher weight, display negative facial expressions, make less eye contact, and often doubt complaints and reports of eating habits and healthy lifestyles from individuals with higher weight [\u003cspan additionalcitationids=\"CR55 CR56 CR57 CR58 CR59 CR60 CR61 CR62\" citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA recent systematic review analyzed 41 studies involving students and healthcare professionals regarding weight stigma and identified that implicit and explicit weight bias is naturalized within this population [\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e]. Therefore, to combat the components of weight stigma at the interpersonal level, academic interventions are needed to raise awareness among student groups on the topic, promote workshops and lectures with healthcare professionals to improve communication between stigmatizing and stigmatized groups, and also support groups affirming the values of stigmatized groups, such as engagement with activism [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Fat activism emerged in the United States, heavily influenced by feminist theories in the 1960s, with the primary goal of advocating for the rights of fat people, challenging negative and stigmatizing ideas about fat bodies, and encouraging acceptance of people's differences [\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eLee and colleagues (2014) evaluated the impact of interventions on beliefs about obesity and discriminatory attitudes, finding small yet positive results [\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e]. Another review conducted by Paolis et al. (2023) demonstrated that educational interventions with healthcare professionals effectively reduced explicit weight bias and that reflective interventions sensitized participants to their prejudice and discriminatory attitudes. These findings suggest the importance of intervening simultaneously across different levels [\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAt the intrapersonal level, the terms implicit weight bias, internalized weight stigma, lipophobia, and fat stigma were classified. All experts agreed with the classification, with only one mentioning that lipophobia could be at the structural level and that the term implicit weight bias could be at the interpersonal level. Here, it is worth highlighting that classifying a term at a given level only considers its origin but clarifies how the levels are affected and mutually interrelated in a bidirectional way \u003csup\u003e(18)\u003c/sup\u003e, hence the choice to keep them at the intrapersonal level, corroborating most experts.\u003c/p\u003e \u003cp\u003eUnlike explicit bias, implicit weight bias is at the unconscious level of the stigmatizing individual. A study carried out in 2020 showed that in cities with a higher prevalence of obesity, the implicit weight bias is lower. In cities with a lower prevalence of fat bodies, there is a more significant internalized weight bias [\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e]. The hypothesis raised by the authors is that where there is less presence of larger bodies, there is a hostile treatment and environment for such bodies since this inner cognitive aspect of people is a predictor of discriminatory processes. The consequences for the stigmatized group are worse health markers related to chronic psychosocial stress when compared to the results referring to explicit weight bias [\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eInternalized weight stigma is associated with poorer quality of life indicators among stigmatized individuals, as they tend to internalize societal concepts about themselves, leading to feelings of incompetence, self-hatred, or devaluation [\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eLipophobia is a rarely used term that refers to a fear of becoming fat, particularly in a society where fatness carries such negative connotations. Individuals experiencing lipophobia commonly struggle with the conflict between being seen as beautiful and accepted versus being viewed as ugly and rejected. This is because the process of pathologizing fatness has associated it with ugliness and illness, as mentioned earlier [\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFat stigma refers to an individual experience of the stigmatized individual, which begins with the \"social death\" of the individual due to their body weight. Psychological and mental outcomes are worse in those individuals who suffer from this \"social death\" and contribute to the development, maintenance, and worsening of low self-esteem, depression, anxiety, concerns about body image, and binge eating [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eInterventions at this level should include affirming positive values for the stigmatized group and enhancing their self-efficacy and sense of belonging. It is also important to emphasize that interventions at this level exemplify the multidimensionality and bifactorial nature of the model, as they may involve interventions with stigmatizing groups akin to interpersonal-level interventions. Recommendations for interventions with stigmatizing groups also contribute to addressing aspects of stigma at the interpersonal level by broadening cultural understanding among individuals [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Evidence in the literature indicates that educational approaches (combined across levels) have been effective in reducing stigma related to mental illnesses [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThird-wave behavioral therapies based on mindfulness are promising tools for intrapersonal interventions. In this approach, the target for change is not the content, intensity, or frequency of the thoughts themselves but rather the context, function, and manner of relating to them, thereby improving the ability to respond to self-stigmatizing thoughts [\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e]. A study aimed at determining the efficacy of mindfulness-based approaches in addressing self-stigma and shame showed positive outcomes, such as increased self-compassion and shame reduction. Additionally, it is a technique that positively impacts quality of life and aspects of psychological health [\u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe potential of our study lies in being the first, to our knowledge, to delve into analyzing the components that constitute weight stigma, aiming to classify them according to their origins and how they interrelate and mutually influence each other. This study is highly relevant in aiding efforts to combat stigma, offering a clear and precise approach based on understanding this categorization. As for the study's limitations, we can mention the relatively small number of expert analyses. However, the analyses received were comprehensive, supported by theoretical and scientific foundations, and provided by professionals with substantial experience and significance in research.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWe presented a comprehensive multi-level classification of weight stigma components, as follows: Fatphobia and weight-based stereotypes at the structural level; weight discrimination and explicit weight bias at the interpersonal level, and implicit weight bias, internalized weight stigma, lipophobia, and fat stigma at the intrapersonal level. It is emphasized that there is a bidirectional relationship between these levels, and recent evidence highlights the importance of multi-level stigma-reducing interventions.\u003c/p\u003e \u003cp\u003eIn future studies, this classification can help assess the association between inter- and intra-level components of weight stigma and guide interventions across different levels, specifying the component that is the focus of the intervention. This approach aims to facilitate organized knowledge construction that is intelligible for researchers, healthcare professionals, and society.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics approval and consent to participate:\u003c/h2\u003e \u003cp\u003e Research approved by the ethics and research committee of the Clinics Hospital of Ribeir\u0026atilde;o Preto of the University of S\u0026atilde;o Paulo. Protocol: 43226821.6.0000.5440\u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e \u003cp\u003eThis study was financed in part by the Coordena\u0026ccedil;\u0026atilde;o de Aperfei\u0026ccedil;oamento de Pessoal de N\u0026iacute;vel Superior - Brasil (CAPES) - Finance Code 001 and by the Universidade de Ribeir\u0026atilde;o Preto \u0026ndash; UNAERP.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAuthors' contributions and e-mailsGCA de S has contributed to the conception and design of the work, the acquisition, analysis, and interpretation of data, and has drafted the work. ([email protected])MFL has contributed to the conception and design of the work, the acquisition, analysis, and interpretation of data, and has drafted the work. ([email protected])FROP has contributed to the acquisition, analysis, and interpretation of data. ( [email protected])LB dos S has contributed to data acquisition, analysis, and interpretation. ([email protected]) CCJ has contributed to the conception and design of the work, the acquisition, analysis, and interpretation of data, and has drafted the work. ([email protected])All authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe acknowledge the committee of experts for their voluntary and competent participation in this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003e\u003cspan\u003eGoffman E. Stigma; Notes on the Management of Spoiled Identity. Englewood Cliffs, N.J.: Prentice-Hall; 1963.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eLink BG, Phelan JC. Conceptualizing Stigma. 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J Contextual Behav Sci. 2022;23:174\u0026ndash;89. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jcbs.2022.01.006\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Obesity, Weight Stigma, Weight Bias, Weight Discrimination, Intervention","lastPublishedDoi":"10.21203/rs.3.rs-4660605/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4660605/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e \u003cp\u003eWeight stigma is a complex construct formed by various components. This study aimed to compile these components and classify them into the multilevel intervention levels of stigma (structural, interpersonal, and intrapersonal).\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003eA non-systematic literature review was conducted to identify the most commonly used definitions of weight stigma components. Subsequently, a proposal was made to classify these components into different intervention levels as proposed (Structural, Interpersonal, Intrapersonal). The components were categorized based on their definitions and specificities at each level. A panel of experts evaluated the proposal, and the degree of agreement was assessed using Fleiss' Kappa coefficient (₭). Values of ₭ between 0.40 and 0.60 indicated moderate agreement; between 0.61 and 0.75, good agreement; and above 0.75, excellent agreement.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eTen terms were identified and classified in the different levels of stigma, except \u0026ldquo;Weight stigma\u0026rdquo; and \u0026ldquo;Weight bias\u0026rdquo;. At the structural level were included \"fatphobia\" and \"weight-based stereotypes\"; at the interpersonal level, \"weight discrimination\" and \"explicit weight bias\"; and at the intrapersonal level, \"implicit weight bias\", \"lipophobia,\" \"fat stigma\", and \"internalized weight bias\". Agreement among the experts' responses for the structural and interpersonal levels was 100% (₭ = 1.0). For the components allocated at the intrapersonal level, there were some disagreements in the classification of the \u0026ldquo;Fat stigma\u0026rdquo; component (₭ = 0.4), and \u0026ldquo;Lipophobia\u0026rdquo; and \u0026ldquo;Implicit weight bias\u0026rdquo; were considered inappropriate by one specialist (₭ = 0.6).\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe proposed classification of weight stigma components across multi-level interventions is novel and deemed appropriate by the experts. In future studies, this classification can help assess associations between weight stigma components across inter- and intra-levels and guide interventions across different levels for more effective outcomes in combating weight stigma.\u003c/p\u003e","manuscriptTitle":"End of Weight Stigma: A Proposal for a Multilevel Classification of its Components for Intervention Purposes","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-29 17:16:16","doi":"10.21203/rs.3.rs-4660605/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3507fd61-3a35-4fd2-a57a-1dd3323bebc6","owner":[],"postedDate":"July 29th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-12-06T01:08:25+00:00","versionOfRecord":[],"versionCreatedAt":"2024-07-29 17:16:16","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4660605","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4660605","identity":"rs-4660605","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}