Asia is witnessing a burgeoning public health challenge with the escalating prevalence of obesity. Currently, the Asia and Pacific regions contain the majority of the world’s overweight and obese population, numbering around 1 billion individuals. This demographic comprises a larger proportion of the population than those with normal or underweight, underscoring the gravity of the situation in the region.¹ A systematic review by Ni et al.² reported that the prevalence rate of obesity in the Southeast Asian region has dramatically increased over recent years, with the highest rate in Cambodia (50.2%), followed by Singapore (29.3%), Malaysia (19.4%), and Brunei (15.4%). Furthermore, another systematic review reported the prevalence rate of obesity in South Asia and found that Bangladesh has the highest rate of overweight and obesity at 56.6%, followed by India with the rate of 36.1% and Sri Lanka at 26.2%.³ Despite the well-documented prevalence and impacts of overweight and obesity in Asia, there remains a low level of awareness regarding their associated risk factors.⁴ Various factors contribute to the rise in excess weight in the region, encompassing genetic predispositions, certain medical conditions (such as Cushing’s disease), the use of specific medications, unhealthy lifestyle practices, and discrimination based on weight. Additionally, psychological issues like depression, anxiety, and self-disgust are among the contributors.⁵ However, the primary focus of this paper is to delve into weight-related discrimination as a distinctive risk factor in Asia.

For these reasons, it is important to understand weight-related discrimination. In Asia, the stigmatization of individuals who are overweight or obese is considered socially acceptable, representing a form of discrimination.^6,7 This acceptance is attributed to a lack of awareness regarding the harmful impacts of weight stigma on individuals dealing with overweight and obesity. Therefore, the aim of this paper is to delve into the phenomenon of weightism in Asia. This exploration commences with an examination of weightism across various settings and domains, followed by an exploration of the psychological and behavioral consequences experienced by individuals with overweight and obesity. The paper concludes by discussing the practical implications for addressing weightism in diverse domains.

Weightism, alternatively referred to as weight stigma or weight-related discrimination, is characterized by negative treatment, including stereotypes, prejudice, and discrimination, directed at individuals with larger body sizes.⁸ In Asia, weightism is on the rise, manifesting as stereotypes (e.g., associating larger body size with laziness and lack of discipline), discrimination (e.g., limited employment opportunities or hindered workplace advancement for individuals with larger body sizes), and prejudice (e.g., viewing individuals with larger bodies as unclean or unintelligent). These beliefs persist strongly in Asian culture, influenced by entrenched notions of beauty ideals.^9,10 Although there are subtle cultural differences across Asian countries, these variations significantly shape the experience of weightism based on societal values, norms, and beauty standards. In East Asian countries such as Japan, China, and South Korea, there is a strong cultural emphasis on slimness as the ideal body type, perpetuated by media and the K-beauty industry, which often promote unrealistically thin physiques.¹¹ In contrast, South Asian countries like India, Bangladesh, and Pakistan view a curvy body as a sign of health, fertility, and wealth in traditional settings. While weightism exists in South Asia, it tends to be less emphasized compared to other prevalent forms of discrimination in the region, such as caste, gender, or religious discrimination.¹² Meanwhile, in Southeast Asian countries like Thailand and Malaysia, weight-related comments among family and friends are often framed as expressions of concern rather than mockery. However, body size is heavily scrutinized in professional contexts, where it is often seen as an indicator of productivity and capability.¹³

This underscores weightism as a socially and culturally constructed phenomenon. Extensive evidence indicates that young Asian women face significant distress and societal pressure, both from their loved ones and the broader community, to conform to the ‘ideal body’ standard of being slender and delicate.^14-16 While some efforts have aimed to address weightism, research on weightism and its impacts in Asia remains limited, with a corresponding lack of awareness on weight stigma. This knowledge gap may contribute to the escalating prevalence of weightism, consequently heightening the risk of obesity. As highlighted earlier, weightism permeates various domains in Asia, encompassing homes, workplaces, schools, healthcare settings, and the media. Therefore, this section is dedicated to prior studies on weightism in diverse settings.

Weightism at home

Weight-related discrimination emerges early in life, particularly within the confines of one’s home. A growing body of evidence indicates that family members are primary sources of weight stigma for overweight and obese adolescents and adults.¹⁷ Stigma within the family is particularly concerning as family is expected to provide love and emotional support, and failure to receive such support can significantly impact an individual’s mental well-being, leading to self-hatred or self-disgust. Moreover, family-based stigmatization can impede the development of trust.¹⁸ While existing research has predominantly focused on weightism in public settings, limited attention has been given to weightism within the home. In the Asian culture, family teasing or discrimination regarding weight typically begins around the age of 14, persisting into adulthood for most individuals with excess weight.^19,20 Family members may harbour negative stereotypes and attitudes, leading to nagging and insults from their family members.

In a study conducted by Mellor et al.²¹ sociocultural risk factors for body dissatisfaction were investigated among Malaysian adolescents. The findings revealed a notable association between body dissatisfaction and familial pressure to lose weight among Chinese girls. This suggests a higher prevalence of weightism in Chinese culture compared to Indian or Malay cultures; this is contradictory to traditional Chinese beliefs associating a larger body size with good fortune.²² While larger body sizes are valued in middle adulthood for symbolizing health and prosperity, adolescence sees a preference for slim ideals driven by modern influences, creating conflicting pressures for Chinese females.²³ This contradicts studies in Western cultures; for example, Ames et al.²⁴ found that parents and family members in Western cultures employ behavioral weight avoidance strategies rather than discussing their child’s weight. This includes verbal avoidance, such as directly or indirectly avoiding weight-related discussions, and behavioral avoidance, such as switching the TV channel when a weight-related program airs or altering dinner to appear less healthy to divert attention from their child’s weight status. Parents also were found to be cautious with their choice of words when discussing weight.

Another study by Noh et al.²⁵ explored the relationship between self-perceived weight status and body image in South Korea and Taiwan. The results indicated that underweight and healthy weight South Korean and Taiwanese women tend to overestimate their weight, perceiving themselves as overweight. Further investigation revealed that weight teasing by family members and negative weight-related comments by siblings, typically beginning at the age of 9, contributed to distorted perceptions of weight and body image among South Korean and Taiwanese women. This finding aligns with the observed increase in the rate of liposuction surgery in South Korea each year.²⁶ Extensive data also indicate that Asian females, in comparison to males, experience higher levels of stigmatization at home for their weight.^27,28

Weightism in the workplace

Weight-based stereotypes and prejudices infiltrate the workplace, starting as early as the recruitment and interview stage for employment.²⁹ Individuals with larger body sizes often face weight-related discrimination at work, fueled by stereotypical beliefs that link overweight or obese to laziness and lack of discipline. Moreover, their intelligence and competence in the workplace are frequently criticized and questioned.^30,31 Notably, research indicates that obese women experience an average wage penalty of 8% to 10% compared to their counterparts.^32,33 A study by Ji et al.³⁴ aimed to assess how management in China evaluates the performance of overweight and obese colleagues. The sample included 266 supervisor-employee duos, predominantly comprising male participants. Supervisors completed questionnaires focusing on anti-fat bias, perceptions of employee weight changes, and performance evaluations. The study found that employees who had recently lost weight received more positive performance evaluations, while those who had gained weight received more negative evaluations from the management. However, when these measures were revisited after 6 months, the study revealed a positive correlation between anti-fat bias, weight gain among employees, and subsequent negative performance evaluations.

A review of studies in China examining the significance of body weight in labor market outcomes revealed substantial impacts on Chinese individuals’ career opportunities based on their body size, with variations by gender and occupational hierarchy.³⁵ Slimmer women, for instance, had higher chances of enjoying exclusive benefits in the workplace and of securing long-term employment contracts. In contrast, overweight and obese women faced obesity penalty effects, often receiving short-term employment contracts. Moreover, these employment contract dynamics varied based on occupation, with more pronounced advantages of slimness in lower International Socio-Economic Index (ISEI) occupations, while the obesity penalty was more evident in those with higher ISEI.³⁶ These findings suggest that, while the Chinese labor market generally tolerates variations in men’s body size, it places significant demands on women’s body size, indicating heightened pressure and challenges for Asian women in the workplace.

Another study demonstrated that obese employees in Japan were less likely to receive promotions, salary increases, or genuine recognition at work compared to their slimmer counterparts, despite demonstrating comparable skills and qualifications.³⁷ In a more recent review, Ramachandran and Snehalatha⁵ emphasized that, as obesity is considered a growing concern in Asia, particularly in career settings, where individuals spend a substantial portion of their lives at work,³⁸ discrimination and ignorance at work can lead to poor performance, diminished motivation, and an increased sense of worthlessness. Furthermore, the lower is the awareness of weightism in Asia, the more pronounced are these impacts likely to be. Most previous studies on weightism in the workplace have been conducted within Western cultures, resulting in limited evidence in the Asian literature regarding weight discrimination in work settings.

Weightism in healthcare

Surprisingly, a growing body of evidence reveals that weight-based discrimination is prevalent in healthcare settings, leading individuals with larger body sizes to encounter numerous barriers when seeking healthcare assistance.^39,40 Paradoxically, healthcare professionals (HCPs), including general practitioners, nurses, dieticians, pharmacists, physiotherapists, psychologists, and obesity experts, whose responsibility is to assess patient health and well-being and provide health support, often exhibit negative attitudes toward overweight and obese individuals due to higher levels of weight bias.^41-43 In a study by Wang et al.⁴⁴ that examined the attitudes of Chinese registered nurses toward obese individuals, 297 nurses answered questionnaires on the Attitudes Toward Obese Persons (ATOP) scale and the dieting belief scale. Unlike findings from Western-based studies, the majority of Chinese registered nurses displayed neutral to slightly positive attitudes toward obese individuals. Notably, nurses working with obesity-related diseases were aware of the risk factors and causes of obesity and those who believed that obesity is not solely an individual’s fault exhibited more frequent positive attitudes toward obese individuals, treating them equally and without bias. This evidence underscores that, despite comprehensive education in healthcare, the lack of understanding of interpersonal skills development, especially when addressing weight as a sensitive topic, can lead to mistreatment of obese individuals.^42,45 In a similar study by Iwabu et al.⁴⁶ examining the perception and attitude of obese individuals toward HCPs in Japan, 56% of obese individuals expressed positive feelings after discussing their weight-related struggles with their HCPs, and only 2% felt offended by their HCP attitudes. These findings suggest that weight-based discrimination in East Asia is comparatively low compared to other settings like home, work, or school.

Weightism in the media

The sociocultural theory of body image posits that media plays a significant role in societal expectations and beliefs regarding body size.⁴⁷ Media encompasses various forms, including broadcast media such as television and radio programs, newspapers, and magazines, as well as social media platforms like Facebook, YouTube, Instagram, Twitter, TikTok, WhatsApp, and Internet search engines like Google or Yahoo. Despite one in five adults being overweight or obese, extensive data indicate that overweight and obese characters are a minority on television. Moreover, when they do appear in media, they are often subjected to discrimination and stereotyping based on their body size. Additionally, these characters are frequently the primary targets of comedic portrayals.^48,49 Surprisingly, popular children’s TV shows that are accountable for playing a role in instilling moral values in children are deeply stigmatized, and obese characters are targets of teasing and mockery, such as addressing an obese woman as, ‘The Fat Lady.’⁵⁰ In addition, a scene in the renowned film Kung Fu Panda involves the main character commenting, “Look at you! This fat butt, flabby arms... and this ridiculous belly!”⁵¹ A study conducted by Lau and Mohd Don⁵² investigated representation of the female body in advertisements in Malaysia. The findings revealed that overweight or obese individuals are seldom featured in non-weight-related advertisements, regardless of the product or service being promoted. However, a significant portion of overweight and obese individuals is prominently featured in dieting or slimming advertisements, often portraying the journey from fat to fit. Predictably, these advertisements frequently perpetuate fat phobias, depicting larger-sized women as unattractive, depressed, and repulsive to create societal apprehension.^47,48 Moreover, these advertisements reinforce the societal standard that being slim equates to beauty. Beyond impacting the mental well-being of overweight and obese women, these advertisements also contribute significantly to the proliferation of weightism in society.

In a study by Su et al.,⁵³ the social constructs of obesity on China’s widely used social media platform, ‘Weibo,’ were examined. The analysis of 222 posts containing the keywords ‘obesity’ or ‘obese’ revealed that public stigmatization of obese individuals was more likely when the media framed obesity as a cosmetic problem. The overemphasis on obesity as a cosmetic issue was associated with harsher comments, negative attitudes, and stereotypes towards obese individuals. Clark et al.⁵⁴ argued that harsher comments and posts related to overweight and obesity are more prevalent on social media compared to mass media, possibly due to the anonymous nature of social media. This may explain why weightism is significantly exacerbated on social media platforms.

Conversely, social media is also used as a platform to promote body positivity, and numerous efforts have been made to challenge negative weight-based discrimination and increase public awareness of the dangers of weight stigma and self-stigma.⁵⁵ However, despite these efforts, weightism remains common in Asia, suggesting that the initiatives to raise awareness about weightism do not capture the public’s attention.

Summary

In summary, ample evidence indicates that weight-based discrimination tends to originate at home and permeate various aspects of an individual’s life (Fig. 1). The stigma and stereotypes against overweight and obese individuals persist strongly in Asia, where such people are often unfairly labelled as lazy, unintelligent, and lacking discipline. This discriminatory attitude is sometimes justified under the notion that negative treatment serves as motivation. However, from the perspective of individuals with larger body sizes, weightism negatively affects both physical and mental well-being over an extended period. The pervasive nature of weight-based discrimination underscores the need for increased awareness, education, and efforts to foster a more inclusive and understanding society.

Despite the widespread acknowledgment that stigma and stereotypes are counterproductive to the fundamental principles of equality, weight stigma remains widespread in Western cultures.⁵⁶ While some may argue that weightism serves as motivation for weight loss, there is no evidence supporting its overall benefits for individuals struggling with weight issues. On the contrary, a substantial body of evidence indicates that weight-related discrimination has severe physical, psychological, and social consequences, potentially leading to morbidity or mortality.^57,58 Weightism not only triggers physiological, psychological, and behavioral changes, but also contributes to the obesity epidemic. The accumulation of fat is linked to significant health problems, including cardiovascular disease (coronary heart disease and stroke), type 2 diabetes mellitus, cancer (breast, colon, and endometrial), high blood pressure (hypertension), musculoskeletal diseases like osteoarthritis, as well as sleep apnoea and respiratory problems.⁵⁹ These health consequences can result in a low quality of life, potentially leading to substantial mobility issues or mortality. Previous research has established a strong association between weight stigma and various psychological issues, such as eating disorders, depression, anxiety, self-disgust, self-hatred, and tendencies toward self-harm.⁶⁰

A comprehensive review of key studies investigating the psychological repercussions of weight stigma has affirmed that one of its major effects is weight self-stigma.^61,62 Weight self-stigma is characterized by personal feelings of shame, self-devaluation, poor self-worth, and perceived discrimination.⁶³ Exposure to discrimination or stereotypes based on body size can lead individuals to internalize stigmatized beliefs, fostering a belief that they are lazy, lacking in willpower, or unattractive. This internalization can gradually influence behavior in various life challenges, resulting in unhealthy eating patterns, social isolation, diminished academic or work progress, or even suicidal tendencies. These manifestations contribute to distorted and negative self-perception, aligning with the principles of the self-perception theory by Bem,⁶⁴ which posits that individuals become more aware of their attitudes and emotions based on their own behavior. Moreover, overweight and obese individuals commonly experience significant body dissatisfaction, influenced by societal pressure to conform to slimness ideals perpetuated by the media.⁶⁵ Media representations often depict overweight or obese individuals as unattractive or unhappy, contributing to heightened body image concerns and reduced life satisfaction.

Earlier research has indicated that individuals subjected to high levels of weightism are inclined to adopt unhealthy weight loss methods involving maladaptive eating behaviors,^66,67 often followed by rapid weight regain. This cycle contributes to increased levels of depression and low self-esteem. Furthermore, Lee et al.⁶⁸ argued that heightened experiences of weightism also cultivate anti-fat prejudices among overweight and obese individuals.

Similar to other forms of discrimination, weightism can profoundly affect mental health, potentially increasing the risk of mental health disorders such as eating disorders, depression, anxiety, and even psychosis.⁵⁷ Research has shown that weightism is strongly linked to a wide range of disordered eating behaviors, including restrained eating, binge eating, and disinhibited eating.^69,70 Additionally, weight teasing can exacerbate anxiety about going out, choosing suitable clothing, and fearing ridicule from others, potentially escalating into severe anxiety or the onset of social anxiety disorder.⁷¹ In summary, weightism can have detrimental impacts on individuals grappling with weight-related issues, emphasizing the need to better understand and address this problem to mitigate the risk of severe physical and mental health issues.

Research suggests that efforts to prevent obesity are hampered by weight stigma, which simultaneously worsens health inequities. Unfortunately, the Asian governments are yet to address weightism and discrimination in an official legislation, causing millions of overweight and obese individuals to endure social injustice due to their body size.⁷² Although it will be difficult and improbable to completely eradicate weight stigma and discrimination, reducing these could be an attainable goal (Table 1).

Public health community

To tackle the pervasive unfair treatment faced by overweight and obese individuals, the public health community could initiate an obesity stigma prevention campaign. This campaign would emphasize the importance of non-stigmatizing language and educate the public about the adverse impacts of derogatory words such as lazy, unattractive, undisciplined, or stupid when referring to individuals with overweight or obesity. Adopting weight-neutral terms like ‘higher weight’ or ‘lower weight’ instead of terms like ‘fat,’ ‘morbidly obese,’ or ‘extra-large’ has gained recognition in Western cultures and has proven effective in reducing weight stigma.⁷³ Legislation plays a crucial role in ensuring equality for vulnerable groups in society. While only a few states, such as Michigan in the United States and the City of Reykjavik in Iceland, have taken official legislative actions to address weight-related discrimination across various sectors, it is crucial for Asia to establish similar weight discrimination laws to better protect individuals living with obesity. For example, Michigan Legislature section 37.2202 prohibits employers from discriminating against individuals in the workplace based on their appearance, body size, or physical attributes.⁷⁴ Given the significant role of the media in perpetuating stigmatized views of obesity, the establishment of a code of ethics for media and professional journalist societies is essential. Penalties should be implemented for breaches of these ethical guidelines. Additionally, social media sites should explicitly address weight bias and discrimination in their community guidelines. Enforcement of these guidelines, which is often lacking on newer platforms, is not difficult, as the majority of platforms already have policies against potentially dangerous content like violence, bullying, or hate speech.

Workplace practices

The workplace is a practical and logical setting for initiating healthcare interventions, given that a significant portion of individuals spend a considerable amount of their day at work. Recognizing that one-third of our lives is devoted to work and that physically and mentally healthy employees are essential for sustained employment, efficiency, and productivity, the workplace is a primary arena for promoting health. In numerous Southeast Asian countries, corporations have implemented employee assistance programs (EAPs), in which registered counsellors and psychologists assist both employers and employees in managing personal and work-related challenges.⁷⁵ Many EAP coaches routinely provide health and mental well-being sessions to employees, covering topics such as stress management, healthy lifestyle choices, and emotion management. This presents an excellent opportunity for EAP coaches to educate employers and employees about weight-based stigmatization, emphasizing its unacceptability and the harm it can cause, even in the form of minor teasing. To further address weight-based discrimination in the workplace, weight-based stereotypes should be explicitly incorporated into workplace anti-bullying policies. These policies should ensure that instances of weight-based discrimination are promptly addressed and thoroughly investigated. Another crucial aspect to eliminate workplace inequities is addressing unfair treatment of individuals dealing with weight issues, including issues such as biased hiring practices, lower wages, and improper job terminations.

Previous studies have highlighted the effectiveness of sensitivity training to hiring managers and employers. Sensitive training involves psychotherapeutic techniques, including group discussions and interactions, to educate employers on self-awareness of their attitudes and behaviors towards themselves and individuals from diverse backgrounds. The primary goal of sensitive training is to enhance social sensitivity and behavioral flexibility, fostering understanding between employees of different backgrounds and promoting positive interpersonal relationships.⁷⁶ This approach ensures fair treatment in various employment practices, such as interviewing, hiring, and promotions, irrespective of an individual’s body size. In summary, fostering a healthy workplace involves creating a supportive environment that promotes appropriate language, increases awareness of weight stigma, and encourages employees to engage in evidence-based mental health and emotion management programs to address their struggles effectively.

Healthcare practitioners in clinical practice

Addressing weight stigma in clinical practice poses challenges for HCPs who must balance promoting body positivity while educating patients on the risk factors of overweight and obesity.^39,40 This dual role can be difficult, as patients may experience weight stigma during the process, potentially hindering them from seeking necessary treatments. Healthcare providers should begin by examining any weight bias or stigmatizing views they may hold, ensuring that they provide equitable treatment regardless of body size. Pearl⁷⁷ demonstrated that assisting patients in exploring and addressing their weight self-stigma and beliefs through psychotherapeutic approaches can help them understand and overcome unhealthy beliefs hindering their physical and mental well-being. A novel approach called ‘weight-inclusivity’ has been implemented in Western cultures to target weight stigma among overweight and obese individuals. Extensive data show improvements in reducing weight self-stigma and decreasing body mass index over the long term among participants receiving the weight-inclusivity intervention.^78,79 This approach not only benefits individuals struggling with weight, but also educates healthcare practitioners on the far-reaching consequences of weight stigma and the strategies and benefits of reducing weight-based discrimination.⁸⁰ Therefore, clinicians, health practitioners, psychologists, and life coaches should engage in this intervention to ensure a weight-inclusive approach in clinical practice.

Furthermore, Puhl et al.⁸¹ found that patients exhibit higher levels of motivation and interest in interventions or programs that avoid focusing on body size or obesity. Interventions emphasizing healthy behaviors such as self-care, self-compassion, intuitive eating, and stress management receive more attention and interest than those targeting weight or obesity-related issues. Additionally, evidence suggests that patients engaged in positive and supportive conversations with their practitioners show more motivation and interest in suggested interventions compared to those experiencing stigmatization during conversations.⁸² Therefore, fostering uplifting and comforting dialogues in clinical practice can contribute to better patient engagement and outcomes.

Research

There is a scarcity of studies on weight stigma in Asian literature, and the extent of psychological distress resulting from weight stigma and its potential impact on poor physical well-being largely are unknown. Additionally, it is crucial to assess and comprehend the risk factors of weightism and consider the role of culture in shaping weight bias. This understanding holds significant importance in the development of interventions that adopt a weight-inclusive approach for the public. Furthermore, these research findings have implications for informing policies, shaping practices, and guiding future research endeavours in Asia.

This review underscores the extent of weightism across various aspects of life in Asian countries, emphasizing the potential adverse effects on both physical and psychological well-being, with implications for mobility issues or even mortality. The study highlights the persistent need for societal changes to address the widespread stigma and discrimination faced by individuals with overweight and obesity in Asia. To combat weightism, several practices are suggested, including initiation of weight stigma prevention campaigns, raising awareness about the significance of appropriate and destigmatizing language when discussing body weight, integrating weight into workplace anti-bullying policies, incorporating weight bias into the community guidelines of social media platforms, and developing weight-inclusive interventions in both workplace and clinical settings. These measures are proposed to contribute to the reduction of weightism in Asia, fostering empowerment for individuals to improve their physical and mental well-being irrespective of their body size.

The authors declare no conflict of interest.

Study concept and design: SM; acquisition of data: SM; analysis and interpretation of data: SM; drafting of the manuscript: SM; critical revision of the manuscript: PLL; and study supervision: SM and PLL.