With increasing incidence obesity in Asia  and Singapore , the prevalence of obesity-related stigmatization is expected to increase, with psychological and physical ramifications for obese individuals, as well as important public health implications . To our knowledge, this study was the first on the prevalence of perceived social stigma experienced by individuals in an Asian population. The current study reported a 60.4% prevalence of perceived stigmatization, which was remarkably like the 55.6–61.3% reported in Western literature , once again confirming the authors suspicion that weight-based discrimination is equally prevalent in Asia as well. Additionally, even though only 33.7% of respondents have been blamed by others for their weight issues, nearly double (60.4%) of respondents have felt stigmatized, criticised, or abused. The authors postulate that this discordance between actual discrimination and perceived stigmatization may reflect an overwhelmingly disproportionate attribution of self-blame or self-perception of stigmatization in respondents with obesity.
The study population represented a sample of patients attending a multidisciplinary weight management clinic in Singapore. Tan and Wong previously reported the results of patients attending a nonsurgical weight management clinic in Singapore . In contrast to the group of patients reported by Tan and Wong in 2014 , the current study had a larger proportion of Malays (33.7% vs. 8.6%). The average BMI of patients was also higher in this study (39.3 vs. 35.7). The authors believe such a finding is likely a result of the higher prevalence of obesity in Malays in Singapore . Afterall, the Malay ethnic group had the highest prevalence of obesity, followed by Indians and then the Chinese, even though Chinese make up the ethnical majority in Singapore . The authors postulate that the increased proportion of Malay ethnical groups in this study, may suggest that there has been an increased access to weight management services by the Malay ethnical groups over the years. However, given that most respondents presenting to the clinic in this study are still Chinese, despite the prevalence of obesity being higher in Malay and Indian ethnical groups, additional public health efforts may still be necessary to raise awareness of obesity and its management options amongst these ethnic subgroups.
The study findings reported significant differences in obesity classes across various socioeconomic groups. Significantly, respondents from the lower income group were more likely to have a higher BMI. This parallels the trends seen in many other developed countries [2, 12]. One of the common explanations was the disparity in food prices, in particularly the decline in prices of calorie-dense foods and increase in prices of fresh produce , which leads to preferential spending on more inexpensive and unhealthy foods for those of a lower socioeconomic status . While commonly reported in the West that a lower educational qualification was associated with a higher prevalence of obesity [18, 19], such a finding was only true to a certain extent, as a significant proportion of respondents with class III obesity had attained at least secondary and post-secondary school education. These less consistent trends appear to be not dissimilar in Asian societies. In Japan and Korea, gender differences appear to account for the disparities in education level and obesity. For males, education level was proportionately related to obesity while the inverse was true for females [20, 21]. In the current study, even after accounting for gender, there were no significant differences in obesity patterns between gender groups (data not shown). The current study parallels that reported by Taiwan, where class III obesity appears to be most prevalent in patients who had received post-primary education and higher, but the prevalence declines again with tertiary education . The exact explanation is uncertain, but it was likely due to the significant correlation between educational qualifications and income level. The authors postulate that a relative degree of poverty may exist amongst the subgroup of patients who have only attained primary school education qualifications, given that almost all of them (90.9%, 10/11) were in the low-income group, hence limiting the quantity of foods purchased and consumed. Hence, this might explain why there were as many class II and III obese respondents in those who attained primary school education, while most of those who have attained secondary or post-secondary school education were class III obese. But, in general, the trends do suggest that respondents with lower educational qualifications may have lower purchasing power, thus limiting their ability to access diet with good nutritional quality, leading to weight gain .
On the multivariate analysis, compared to class I obesity respondents, class II obesity respondents were significantly less likely to believe that their weight is their own responsibility, which may reflect a reduced motivation to lose weight. A subgroup analysis revealed that 82.6% (19/24) of class I obesity respondents who believed that weight is their sole responsibility have attempted weight loss, compared with only 58.3% (14/27) of respondents with class II obesity. However, it is precisely this group of respondents that weight loss efforts should be targeted to prevent them from progressing to class III obesity.
In the study, even after accounting for baseline socioeconomic differences, it was noted that respondents with a higher BMI, especially class III obese respondents, were more likely to report an increased consumption of unhealthy foods, overconsumption of food or partaking in less exercise in response to perceived stigma, putting this already at-risk group of respondents at further weight gain and obesity-related complications. This alteration in eating behaviour has been previously described [24, 25], and was postulated to be due to a dopamine-based reward mechanism to diminish the negative impact of such stigmatization [26, 27]. In addition to further weight gain, these maladaptive eating behaviours put obese individuals at increased risk of eating disorders including bulimia, binge eating episodes and overeating , as well as mental health conditions such as depression and low self-esteem [28, 29]. Such weight-related prejudice may also worsen body image disturbances , resulting in avoidance of exercise for fear of further stigmatization. Ultimately, this results in a triple detriment. The first being their original obesity, second being their maladaptive eating and exercise behaviours which compounds further weight gain, and thirdly the subsequent medical complications associated with further weight gain.
A commonly held misconception globally is that obesity is preventable, attributed to overeating and a sedentary lifestyle , often ignoring the significant genetic and epigenetic elements behind its pathogenesis . Against this backdrop, the authors believe cultural differences also play a part in perceived weight-based stigmatization. Ran et al previously suggested that Western cultures value individualism, which tend to be more tolerant of diversity and deviation from societal norms, while many Asian cultures still value Confucianism and collectivist values . Thus, on top of the health ramifications associated with obesity, there could be additional prejudice on obese individuals living in Asia. With conformist societal pressures, these individuals could be more likely viewed as not trying hard enough to lose weight or maintain a healthy lifestyle when compared to their non-obese counterparts. This problem might be further compounded by ideal body weight stereotypes perpetuated by the media since childhood . This may account for the high perceived prevalence of low confidence and sense of self-worth (86.9%), low mood and depression (73.8%), as well as self-guilt (74.3%). Also, though the maladaptive eating behaviours in response to stigmatization were also described in Asian Americans , the foods consumed are largely determined culturally. In rice-consuming regions, carbohydrate-rich foods such as rice may be preferentially consumed over Western foods such as oil-rich fried chickens or hamburgers . Also, there appeared to be a higher prevalence of the A1 allele of the D2 dopamine receptor gene (DRD2 A1), which was linked with food addiction, amongst Asian Americans compared to their Caucasian counterparts . The above factors may also serve as barriers to weight loss in Asians, perpetuating weight-based stigmatization.
The study also found significant weight-based stigmatization at the workplace, particularly amongst class III obese individuals, even after accounting for socioeconomic differences. Since the 18th century, stereotypes of obese individuals being “lazy” have been ingrained and perpetuated . In today’s workplace, an obese individual is continued to be perceived as lazy , incompetent , and were less likely to be hired . Given that employment determines income level, and hence purchasing power, such prejudice may generate an obesity “poverty cycle”. Individuals faced with lower income levels because of workplace discrimination, will resort to the consumption of inexpensive calorie-dense foods, which will worsen weight gain, further fuelling employer stereotypes.
On a separate note, most respondents were comfortable discussing weight issues with their doctors, and that only a small proportion of respondents felt stigmatized by healthcare professionals. This contrasted with the results reported by the UK All-Party Parliamentary Group on Obesity study, where up to 42% of respondents in that study did not feel comfortable discussing their obesity with their primary physician .
The limitations of the study include responder bias, as it was performed on a sample of patients attending obesity follow-up in the hospital. Also, being a survey of respondents presenting to a weight management clinic, the motivation level to lose weight, the awareness of obesity as a disease entity and the physical characteristics of the study population may not be representative of the general populace, hence representing selection bias. Lastly, being a questionnaire, it was prone to recall bias. Yet, even with these limitations, the study findings were still valuable. The authors believe it provides a glimpse into the prevalence of obesity stigmatization in Asia. A subsequent qualitative study should be conducted via focused group interviews to gain a more in-depth understanding into the causes, with a focus on any cultural-specific factors, for such perceived weight-based stigmas amongst individuals with obesity, to spur public education efforts on the pathophysiology and knowledge of obesity as a disease entity.
In conclusion, the study findings suggest that obesity stigmatization remain ubiquitous, and is equally prevalent in Asia. Individuals with a higher BMI were more likely to report perceived workplace stigmatization as well as negative adaptive responses to diet and exercise in response to weight-based discrimination, independent of socioeconomic status.