Discrimination and Stigma Associated with Obesity: A Comparative Study between Spain and Egypt – Data from the OBESTIGMA study

The overall projection for global levels of overweight and obesity (body mass index [BMI] ≥25 kg/m²) suggests that by 2035, over 4 billion people may be affected, compared to over 2.6 billion in 2020. This marks an increase from 38% of the world’s population in 2020 to over 50% by 2035. However, this substantial rise will not be uniform across the globe, exhibiting variations based on world regions and countries. For instance, the expected 37% of adults with obesity in Spain by 2035 contrasts with the projected 49% in Egypt by the same year [1]. This discrepancy is reflected in the Global Preparedness Ranking, where Spain ranks 51 and Egypt 103 out of 183 [1].

Obesity is a multifaceted, chronic, and relapsing disease that cannot be solely attributed to an individual’s choices regarding food and physical activity. Its roots extend to a broader consideration of living conditions and context. Various economic, political, commercial, and sociocultural determinants of health, coupled with resulting health inequalities, contribute significantly to the onset and persistence of obesity [2]. Distinct daily living conditions characterize each region, where factors such as birthplace, living environment, education, job income, financial capacity, recreational activities, and aging play pivotal roles in shaping opportunities for accessing healthy foods and engaging in sufficient physical activity for maintaining health or preventing obesity [3]. Similarly, environmental factors such as the availability of parks, recreational facilities, and healthy food outlets can vary significantly by geographic location, affecting individuals’ opportunities for physical activity and healthy eating independently of their socioeconomic status [4, 5]. These critical elements also encompass aspects like family structures and traditions, available resources, employment conditions, and proximity to essential services [6].

The experience of living with excess weight is intricately tied to facing discrimination, prejudice, negative societal attitudes, and self-stigma, resulting in structural exclusions, embodied stress, and an overall detriment to health and well-being [7, 8]. Individuals living with obesity are often burdened with derogatory labels such as “clumsy,” “lazy,” “lonely,” “rejected,” and “vulgar” [9]. Notably, psychological consequences linked to obesity, including anxiety and depression, are particularly prevalent among females [10‒12]. Addressing these social and psychological aspects is essential to fostering a more empathetic and inclusive environment, recognizing the impact of societal attitudes on the well-being of those affected by obesity.

In a surprising turn, our recent research in Spain has revealed that individuals with obesity exhibit a higher level of aversion toward the condition compared to the normal-weight population [13]. This study also displayed a concerning increase in the experience of stigmatizing encounters among younger individuals [13]. In addition, weight loss following bariatric surgery (BS) was unable to reduce social stigma scores to levels equivalent to those observed in individuals with normal weight.

However, discrimination and stigmatization faced by individuals with obesity in Spain have not been previously compared with populations from other countries. Therefore, our objective was to address this gap by comparing the levels of rejection and experiences of stigma related to obesity between Spanish and Egyptian populations. This study encompasses individuals across a diverse spectrum of weights, including those who have undergone BS. To achieve this goal, we administered three well-validated questionnaires – the Antifat Attitudes Scale (AAS), Stigmatizing Situations Inventory (SSI), and the Weight Bias Internalization Scale (WBIS) – to both populations [14‒16]. Furthermore, our study aimed to identify the primary factors associated with the extent to which both societies engage in social discrimination and rejection toward individuals with obesity.

In this cross-sectional observational study, a total of 2,268 adults were invited to participate between January 2019 and December 2022. Participants were concurrently recruited in both countries and included males and females aged 18 years or older and a BMI equal or greater than 18.5 kg/m² who were attending medical check-ups for obesity, along with their companions. Thirteen obesity units in Spain participated in the recruitment, while only one obesity unit in Egypt was involved. A total of 93 individuals were excluded due to various reasons: serious illnesses determining a life expectancy of less than 6 months (7 in Spain, 10 in Egypt), intellectual disability (6 in Spain, 4 in Egypt), severe psychiatric illnesses (schizophrenia, schizoaffective disorder, bipolar disorder, anorexia nervosa, bulimia nervosa, and major depressive disorder; n = 13 in Spain, n = 8 in Egypt), and failure to report BMI (31 in Spain, 14 in Egypt). Additionally, 51 participants in Spain and 34 in Egypt declined participation in the study. Consequently, the final cohort comprised data collected from 2,090 participant: 1,018 from Spain and 1,072 from Egypt. The project protocol received approval from both the Arnau de Vilanova University Hospital Ethics Committee (CEIC-2190) and the Tanta University Research Ethics Committee (34005/8/20). All individuals who agreed to participate in the research provided written informed consent.

Anthropometric data, including weight and height, were collected from all participants on the same day of the interview. BMI was calculated, and subjects were categorized into the following groups: (i) individuals with normal weight (≥18.5–24.9 kg/m²); (ii) overweight individuals (≥25.0–29.9 kg/m²); and (iii) individuals with obesity (≥30.0 kg/m²). Additionally, participants who reported having undergone previous BS at least 12 months before completing the questionnaires were classified into a fourth group. The study also collected information on age, sex, marital status, ethnicity, employment status, educational level, and annual income.

Three questionnaires were completed by all participants. The AFA is an instrument developed by Crandall CS to assess prejudice against individuals with obesity [14]. It consists of 13 questions divided into three subscales: (i) dislike or rejection toward people with overweight or obesity (e.g., “I tend to think that people who are overweight are a little untrustworthy”); (ii) fear of being fat or gaining weight (e.g., “One of the worst things that could happen to me would be if I gained 25 pounds”); and (iii) willpower or the belief that weight is controllable (e.g., “People who weigh too much could lose at least some part of their weight through a little exercise”). Responses are recorded on a numerical scale ranging from 1 (“not at all agree”) to 7 (“strongly agree”). The average of all responses for each subscale and the overall score were calculated, with higher scores indicating stronger attitudes against obesity. The validated Spanish version of the AFA demonstrates good reliability results (Cronbach’s alphas of 0.78, 0.87, and 0.81 for dislike, fear of being fat, and willpower, respectively) [17, 18].

The SSI is a prominent method for measuring stigmatizing experiences associated with being overweight, which may have occurred at least once in a person’s life [16, 19]. Consequently, items are assessed on a 10-point scale, ranging from 0 (“never”) to 9 (“daily”). Due to the impractical length of its full version (50 items), a concise version (10 items) of the SSI has been created. This condensed version proves to be a more time-efficient tool for evaluating experiences with weight-related stigma, exhibiting high reliability (Cronbach’s alphas in different samples ranging from 0.94 to 0.98) [19]. The final score is determined by computing the average of all responses, with a higher score indicating a greater frequency of encounters with stigmatizing experiences.

The WBIS questionnaire is a valuable tool for identifying patients in need of medical assistance to address weight stigma, demonstrating high internal consistency (Cronbach’s alphas = 0.90) [15]. Consisting of 11 items (e.g., “I hate myself for being overweight”), it gauges the extent to which respondents believe that negative stereotypes and self-statements about individuals with overweight and obesity apply to themselves. Responses are on a scale from 1 (“strongly disagree”) to 7 (“strongly agree”), with items 1 and 9 requiring reverse scoring. The final score is derived by computing the average of all responses, where elevated scores on the WBIS indicate strong anti-obesity attitudes.

To the best of our knowledge, there are currently no measures available in the Arabic language to assess the AFA, WBIS, and SSI constructs in Arabic-speaking populations. Consequently, we undertook the translation of the original questionnaire versions into Arabic, which were then shared with medical professionals fluent in both languages to ensure accuracy. To ensure the independence, accuracy, and honesty of participants’ responses, investigators furnished standardized verbal instructions, explicitly stating that there were no right or wrong answers and guaranteeing the anonymity and confidentiality of all responses. Whenever feasible, data collection occurred in the outpatient waiting room, with the majority of participants taking 10–15 min to complete the survey.

Statistical analyses were conducted using the IBM SPSS Statistics package (Version 20.0, Armonk, NY, USA). The normal distribution of variables was assessed through the Shapiro-Wilk test. For normally distributed data, quantitative variables are presented as mean ± SD. Group comparisons utilized the ANOVA test for quantitative variables and Pearson’s χ² for categorical variables. The correlation between continuous variables was assessed using Pearson’s correlation test. Three multivariable linear regression models (enter mode) were employed to evaluate the final score (continuous variable) of each questionnaire, incorporating the following confounding factors in the analysis: age, sex, BMI, country, employment status, and educational level. Age and BMI were considered as continuous variables in this analysis. Model calibration was gauged using the χ² goodness-of-fit test. All “p” values were derived from a two-sided test of statistical significance. The conventional significance level of p < 0.05 was chosen to strike a balance between reducing false positive (type I) errors and avoiding missing real effects (type II) errors. This significance level of 0.05 was applied uniformly to all statistical analyses.

The complete data for the 2,090 individuals who participated in the study are presented in Table 1. The Spanish population was older and had a higher average weight compared to the Egyptian population. Additionally, a higher percentage of Egyptians were married, with university education, unemployed, and underwent BS.

The scores obtained in the three questionnaires (AFA, SSI, and WBIS) for each country are presented in Table 2. In Spain and Egypt, a positive and significant correlation between BMI and the total AFA score was observed (Fig. 1a, b). However, when comparing both countries, the final score of the AFA questionnaire was significantly higher among participants from Egypt (46.5 ± 14.5 vs. 37.2 ± 12.0, p < 0.001), indicating that Egyptians exhibit greater aversion toward individuals with obesity compared to Spaniards (Table 2). This superiority in the overall AFA score was primarily attributed to the results in the dislike domain. In relation to the other two domains of the AFA questionnaire, Spaniards were more inclined to express a fear of being overweight and to believe that obesity is linked to a lack of willpower.

When analyzing each country separately, the AFA total score and the fear domain in Spain exhibited a progressive increase across BMI groups, starting from normal weight (33.7 ± 11.9 and 8.7 ± 4.6, respectively) to participants with overweight (35.5 ± 10.9 and 10.2 ± 5.0) and obesity (38.6 ± 11.9 and 13.8 ± 5.4) (ANOVA p < 0.001) (Fig. 2). Similarly, in Egypt, the total AFA score raised from normal weight (47.8 ± 15.1) to overweight (48.5 ± 13.0) and obesity (50.6 ± 11.5) (ANOVA = 0.023). Notably, in Egypt, the fear of being a subject with obesity significantly decreased from normal weight (7.8 ± 4.0) to obesity (6.5 ± 4.1) (ANOVA p = 0.001).

The total score of the WBIS questionnaire was also significantly higher in participants from Egypt (ANOVA p < 0.001) compared to Spanish results, indicating that Egyptians internalize weight bias more than Spaniards. However, the WBIS exhibited different tendencies in each country (Fig. 1c, d; Fig. 2). Specifically, in Egypt, the total WBIS score progressively decreased from obesity (50.2 ± 11.8) to overweight (45.1 ± 11.7) and normal weight (42.3 ± 11.9; ANOVA p < 0.001). Conversely, the opposite trend was observed among Spanish individuals, wherein the internalization of weight bias increases along with BMI (ANOVA p < 0.001).

Finally, the frequency of exposures to stigmatizing experiences, measured via the SSI questionnaire, increased progressively from normal weight (8.9 ± 11.6) to overweight (14.2 ± 12.4) and obesity (28.7 ± 17.4) in Spanish participants (ANOVA p < 0.001; Fig. 1e, 2). However, no relationship between SSI score and BMI was observed in the Egyptian population, with the lowest score obtained in the overweight group (26.1 ± 22.1 in normal weight, 20.3 ± 18.1 in overweight and 24.8 ± 19.5 in obesity) (Fig. 1f, 2). Interestingly, the overall SSI score was negatively associated with age in both populations, Spain (r = −0.066, p = 0.050) and Egypt (r = −0.138, p = 0.011), indicating that younger participants with obesity are exposed to more weight stigmatizing experiences than older adults.

When data were evaluated according to the gender of the population in both countries, worse results were observed in Spain for women compared to men in the AFA (38.0 ± 15.9 vs. 34.9 ± 15.8, p < 0.001) and WBIS (38.0 ± 15.9 vs. 34.9 ± 15.8, p = 0.005) questionnaires. In Egypt, higher scores were also observed in women in the AFA questionnaire (48.1 ± 14.8 vs. 42.9 ± 12.9, p < 0.001). In addition, when we explored the final score of the three questionnaires only in women, similar results were obtained in the AFA questionnaire (36.8 ± 11.8 in Spain vs. 48.1 ± 14.8 in Egypt, p < 0.001) and the WBIS questionnaire (38.0 ± 15.9 vs. 43.1 ± 13.7, p < 0.001). However, in (19.7 ± 20.3, p = 0.007) disappeared when only women were analyzed (25.4 ± 17.8 vs. 23.9 ± 19.8, p = 0.139).

When the effect of BS was analyzed, contradictory, and opposite trends was observed according to each country. In Spain, the weight loss induced by the bariatric procedure does not seem to affect the total score of any of the three questionnaires (AFA: 38.6 ± 11.9 in subjects with obesity vs. 37.7 ± 12.5 after BS, p = 0.456; WBIS: 41.7 ± 15.2 vs. 40.8 ± 14.6, p = 0.539; SSI: 28.7 ± 17.4 vs. 27.5 ± 17.5, p = 0.457) (Fig. 3). However, in Egypt, BS was accompanied by a significant improvement in the total score of the AFA (50.7 ± 11.5 vs. 34.6 ± 14.4, p < 0.001) and WBIS (42.3 ± 11.9 vs. 33.7 ± 11.0, p < 0.001), without changes in stigmatizing situations (SSI: 24.8 ± 19.5 vs. 27.2 ± 19.8, p = 0.185).

The multivariate analysis established the differential role of the country in the questionnaires (Table 3). Living in Egypt appears as an independent risk factor for higher AFA and WBIS scores {odds ratio (OR) 8.20 [95% confidence interval: 6.78–9.62], p < 0.001 and OR 6.28 [95% CI: 4.78–7.78], p < 0.001, respectively}. However, Spaniards seem to experience more stigmatizing situations than Egyptians (OR −2.54 [6.78–9.62], p < 0.001). Moreover, the multivariate analysis also confirmed the role of higher BMI, lower age, female sex, and university degree in relation to the final score of questionnaires. However, the employment status was not a significant variable.

This comparative study between Spain and Egypt provides a unique insight into the discrimination and stigma associated with obesity. Although strong differences between both countries exist, data were primarily obtained from public and governmental institutions, with only a few private medical centers (Smart Life Medical Centre in Egypt and Hospital Universitario de Navarra and Clínica Sagrada Familia-CPEN in Spain), ensuring minimal differences in the selection process. Our findings reveal notable differences and similarities in attitudes and experiences concerning weight in both countries. First, the increased aversion toward individuals with obesity in Egypt, compared to Spain, as indicated by higher AFA scores, suggests a more profound cultural impact on obesity perceptions in Egypt. This could be due to specific social norms and body image expectations in the region. Traditionally, weight-related stigma has been viewed as a problem primarily in high-income, industrialized societies that historically valorize thinness, such as the USA, Australasia, and Western Europe. However, emerging evidence suggest that obesity stigma is also becoming a significant issue in middle and lower income populations [20]. This is reinforced by our study, which compares two countries, Egypt and Spain, that show dissimilar poverty rates of 7.8% and 0.4%, respectively [21].

In this study, the positive correlation between BMI and aversion to obesity in both Spain and Egypt indicates a growing perception of stigma with higher weight, mirroring a global trend toward weight-based discrimination [22]. Indeed, a comprehensive survey involving 338,121 individuals across 71 countries revealed that nations with higher obesity rates tend to show stronger implicit negativity towards overweight people compared to thin people [23]. Moreover, our findings are in line with prior research that suggests a universal model of obesity stigma, even in societies traditionally viewed as fat-positive. This points to a widespread global dissemination of negative views on obesity, where anti-fat norms are more prevalent in middle-income and developing countries, such as American Samoa, Mexico, and Paraguay, than in the USA, United Kingdom, and New Zealand [24]. Notably, in Spain, despite lower overall stigma toward obesity, there is an observed increase in weight bias internalization with higher BMI. This could reflect a heightened concern about body image among the Spanish population with overweight and obesity, aligning with trends in Western societies that emphasize thin ideals [25].

The internalization of weight stigma in Spain and Egypt exhibits unique dynamics, potentially shaped by cultural and social factors, as well as the prevalence of obesity. This phenomenon might reflect either a broader cultural acceptance of larger bodies or a resignation to obesity due to its more frequent occurrence and societal normalization [26]. In Spain, with its strong emphasis on the Mediterranean diet and active lifestyle, the internalization of weight stigma could be more pronounced. In a society that places high value on physical appearance and health, individuals with overweight or obesity may feel increased pressure to meet these ideals [27]. Such pressure can intensify stigma internalization, adversely impacting their self-esteem and mental health. Conversely, in Egypt, the decreasing internalization of weight stigma with higher BMI and the stable exposures to stigmatizing experiences regardless of weight is intriguing [28]. This may indicate cultural acceptance of larger bodies, resignation, or normalization due to the higher national prevalence, or perhaps the development of resilience and coping strategies against stigma in Egypt [29]. This assumption aligns with recent research findings by Himmelstein et al. [30] which indicate that coping responses to stigma play an important role in the pathway from stigma to health behaviors. Altogether, these observations highlight the need to consider cultural and social contexts in addressing obesity stigma [31]. They also underline the importance of developing culturally and country sensitive intervention strategies, acknowledging that perceptions and experiences of obesity can greatly differ between countries. In fact, Spain and Egypt exhibit key contrasts in various aspects. For instance, in 2023, Egypt’s unemployment rate was 7.2%, with rates nearly ten times higher for college graduates than for those with elementary education, compared to an unemployment rate of 12.1% in Spain [32]. Additionally, Egypt has one of the world’s largest Muslim populations, with 90.0–94.7% of its citizens identifying as Muslim, compared to only 2.6% in Spain [33]. Regarding healthcare systems, despite Egypt’s basic universal coverage, the public system suffers from chronic underfunding and high out-of-pocket payments, leading many to prefer private services [34]. In contrast, Spain’s National Health System provides primarily free healthcare, ensuring equal access for all citizens. Although these disparities raise concerns about the comparability of both samples, our study captures these contrasts well, reinforcing the validity of our results. Egyptian participants were significantly younger and had higher unemployment rates, while also having a higher percentage of university degrees.

The higher frequency of weight-related stigmatizing experiences in Spain compared to Egypt might be influenced by the widespread use of social media and networks in Spain. In January 2023, Spain had 40.70 million social media users, representing 86.1% of its population, while Egypt had 46.25 million users, accounting for only 41.4% of its population [35, 36]. These platforms often perpetuate negative stereotypes about weight, which can be exacerbated by online anonymity [37]. Social media algorithms might contribute to circulating content that reinforces weight stigma [38, 39]. Such experiences of weight stigma are associated with negative health outcomes, including mental health issues like depression and anxiety, especially in societies where weight stigma is more prevalent and acknowledged, as in Spain [40].

When available, the number of surgeries performed in Egypt is slightly higher than in Spain, equating to 0.0072% of the population in Egypt and 0.0052% in Spain [41]. In our study, the association of BS with stigma reduction varies between both countries. In Egypt, the surgery is associated with improved perceptions and reduction in obesity-related stigma, potentially reflecting more positive societal views on the procedure. This may be influenced by cultural attitudes that view modern medical interventions as effective solutions for obesity [42]. Conversely, in Spain, there are no significant changes in stigma perception between subjects with obesity and those who underwent BS in stigma perception post-surgery. This disparity might stem from different societal expectations and receptions of BS. It is important to recognize that patients undergoing BS face both weight stigma and stigma related to the surgery itself [43]. These cultural and social differences in perceiving the stigma associated with BS could explain the varied outcomes observed in Spain and Egypt [44].

Finally, it is important to recognize the limitations of our study. First, the cross-sectional observational design limits our ability to establish causality between variables. Although the study identifies associations between weight discrimination and factors such as nationality or BMI, it cannot definitively establish direct causation. Second, the data collection, focused on obesity units and their companions in medical centers, may not fully represent the general population of each country, thus limiting the results’ generalizability to broader contexts. Thirdly, a modified version of the WBIS questionnaire was designed to be more inclusive of a broader range of weights [45]. However, the original WBIS has also been validated in numerous populations, demonstrating its applicability across non-obesity weight categories [46‒48]. Therefore, the decision to use the original WBIS in our study was based on its extensive validation and widespread use in the scientific literature, ensuring comparability of results with previous studies. Fourth, despite adjustments for variables such as age, sex, BMI, country, employment status, and education level, other unmeasured factors (e.g., mental health, information on the prevalence of anxiety and depression, previous stigmatization experiences, media exposure, cultural expectations, health differences, selection mechanisms due to variations in healthcare access and healthcare systems, surgical technique, weight loss evolution after the operation, and postoperative support) could affect who ends up in the sample, potentially introducing bias. Consequently, the reported country differences may partly reflect these selection mechanisms. Lastly, the potential impact of linguistic, cultural, and ethnicity differences on the interpretation and responses to the translated questionnaires should be considered.

In conclusion, our study highlights the complex and varied nature of attitudes towards obesity across different cultures. Understanding these cultural differences is essential in devising more effective and culturally sensitive approaches to address weight stigma. Such strategies are crucial for promoting inclusivity and improving the well-being of individuals with obesity, acknowledging the unique challenges they face in different societal contexts.

We thank the Spanish and Egyptian subjects for their participation in this study.

The project protocol received approval from both the Arnau de Vilanova University Hospital Ethics Committee (CEIC-2190) and the Tanta University Research Ethics Committee (34005/8/20). Throughout this research, ethical guidelines outlined in the Declaration of Helsinki and Spanish legislation concerning the protection of personal records were strictly adhered to. Participants were invited to voluntarily contribute to the study, and no financial or additional incentives were provided. All individuals who agreed to participate in the research provided written informed consent.

The authors have no conflicts of interest to declare.

The Spanish Society for the Study of Obesity (Sociedad Española de Obesidad, SEEDO) supported this study.

Conceptualization: A.L. and E.S.; data curation: N.M.E and R.M.E.-S.; formal analysis: A.C. and A.S.-B.; investigation: M.S.H. and H.B.-B; methodology: S.G-M. and L.F.; software: A.M.-S. and F.G.; project administration and supervision: A.L.; visualization: M.S., N.V., J.N., C.M., O.D-T., G.C., and S.C.,; writing – original draft: E.S.; writing – review and editing: N.M.E, R.M.E.-S., and A.L.

The data that support the findings of this study are not publicly available due to their containing information that could compromise the privacy of research participants but are available from the corresponding author (Albert Lecube, alecube@gmail.com).