SUBMITTED 21 JUL 22 1 REVISIONS REQ. 24 AUG & 25 OCT 22; REVISIONS RECD. 18 SEP & 8 NOV 22 2 ACCEPTED 16 NOV 22 3 ONLINE-FIRST: DECEMBER 2022 4 DOI: https://doi.org/10.18295/squmj.12.2022.068 5 6 Stigmatisation of Obesity and its Relation to the Perception of 7 Controllability in Riyadh, Saudi Arabia 8 A cross-sectional study 9 *Fatmah Almoayad,1 Nada Felemban,1 Shikhah A. Alshlhoub,1 Shatha H. 10 Alqabbani,1 May N. Al-Muammar,2 Nada Benajiba3,4 11 12 1Department of Health Sciences, College of Health and Rehabilitation Sciences, Princess 13 Nourah bint Abdulrahman University, Riyadh, Saudi Arabia; 2Department of Community 14 Health Sciences, College of Applied Medical Sciences, King Saud University, Riyadh, Saudi 15 Arabia; 3Department of Basic Health Sciences, Deanship of Preparatory Year, Princess 16 Nourah bint Abdulrahman University, Riyadh, Saudi Arabia; 4Joint Research Unit in 17 Nutrition and Food Regional Designated Center of Nutrition AFRA/IAEA, Ibn Tofail 18 University, Morocco. 19 *Corresponding Author’s e-mail: Faalmoayad@pnu.edu.sa 20 21 Abstract 22 Objectives: This study assessed the stigmatisation of obesity among a sample of the general 23 population in Riyadh and its association with the perception of controllability. Methods: A 24 cross-sectional analytical study was carried out in Riyadh, Saudi Arabia, during January–25 February 2021 and included 384 participants who were recruited through a convenience 26 sampling method. The data were collected using a self-administrated online questionnaire. 27 Statistical analysis was performed using John’s Macintosh Project Version 16.0.0. Results: 28 Most of the participants had a low level of stigma towards obesity (72.8%), and gender and 29 BMI were significantly associated with the level of stigma at (p = .0023) and (p = .0360) 30 respectively. The association between the perception of controllable factors and the level of 31 stigma was also significant (p = 0.0001). Conclusions: The data supported the hypothesis 32 that there would be a significant association between stigmatisation on obesity and perception 33 of controllability among the general population in Riyadh City. Regarding recommendations, 34 the authors suggest that they should be based on joint international consensus statements for 35 ending the stigma of obesity in different settings and categories, and should include the 36 education of healthcare service providers and obese patients on the relationships shown in the 37 findings. 38 Keywords: Obesity, stigmatisation, perception 39 40 Advances in Knowledge 41 There is a low level of stigmatisation of obesity among the general population of 42 Riyadh. 43 The characteristic of gender had a statistically significant association with the level of 44 stigma towards obesity. 45 The stigmatisation of obesity was significantly associated with a perception of 46 controllability. 47 48 Application to Patient Care 49 Policies are needed to prevent weight stigmatisation in different settings, including 50 healthcare. 51 Promoting better healthcare services to obese patients should include educating 52 healthcare providers regarding stigmatisation in relation to controllability perceptions. 53 The healthcare service provided to obese patients should include educational sessions 54 on how to tackle stigmatisation incidents and the relation of stigmatisation to 55 controllability perceptions in the attitudes of those holding those views 56 57 Introduction 58 Obesity is one of the most common and preventable public health issues affecting individuals 59 of both genders and all ages worldwide.1 The global prevalence of obesity has increased 60 almost three times in the last four decades. In 2017, the World Health Organisation (WHO) 61 estimated that 39% of adults are overweight and 13% are obese, while 18% of children and 62 adolescents suffer from being either overweight or obese.2 Being overweight or obese is 63 defined by WHO as “abnormal or excessive fat accumulation that presents a risk to health. It 64 is mainly measured by the body mass index (BMI) by dividing weight in kilograms by the 65 square of height in metres. BMI between 25–29 is considered overweight while BMI of 30 or 66 more is considered obese”. 2 67 68 In Saudi Arabia (SA), in particular, the shift away from a traditional way of living to a 69 Westernised lifestyle and the reduction of the level of physical activity were recognisable risk 70 factors contributing to the growing numbers of individuals that are obese or overweight.3 In 71 2014, 3.6 million Saudis who were 15 or above were obese, and the prevalence was 72 approximately 24.1% for men and 33.5% for women.1 . Being overweight and obese are 73 associated with several health issues that lead to the development of other non-communicable 74 diseases, such as diabetes, heart diseases, and cancer 2 , that increase mortality rates.4 75 Therefore, obesity management is essential for non-communicable disease prevention and the 76 promotion of quality of life.5 77 78 Historically, those who were overweight or obese were positively perceived in Saudi culture, 79 as this was a symbol of high income and wealth for men and good fertility in women.1 80 However, in recent years, obese people have been challenged by stigmatisation at a personal 81 level because of their excess weight and shape.6. A stigma can be defined as “the co-82 occurrence of labeling, stereotyping, separation status loss, and discrimination [in] a context 83 in which power is exercised".7 More than 60 years ago, racial and ethnic discrimination was 84 more prevalent in the world, while current statistics have demonstrated that obesity stigma is 85 becoming more prevalent compared to similar attitudes regarding race and ethnicity.8 This 86 shift has been attributed to Westernisation and the idolisation of thinness9, which is 87 associated with recent social changes in Saudi Arabia.10 88 89 The stigmatisation of obesity has multiple negative effects on obese individuals, such as 90 further weight gain and a deteriorated health status. Some medical ethicists believe that 91 applying a weight stigma and pressuring overweight and obese individuals socially might 92 discourage their attempts in weight management.8 Overweight and obesity stigmatisation can 93 create obstacles to an individual’s daily activities, which can lead to depression, shame and 94 guilt, social isolation, and lower work achievement.5 A study was conducted in the United 95 States with 13,692 heavy adults; of this total, 5,079 demonstrated dangerous consequences of 96 weight stigma that can lead to increased mortality. People who reported experiencing weight 97 discrimination had a 60% increased risk of dying for several reasons, including poor health 98 care services or alcohol and substance abuse.8 99 100 Weight stigma leads individuals to develop a distorted and dysfunctional image of 101 themselves, especially when they are unable to manage their weight. Therefore, this 102 discrimination can create a variety of mental health issues, including affecting attitudes8 and 103 creating an increased risk of experiencing depression, low self-esteem, and low quality of 104 life.11 A study conducted in a university in the north-eastern United States found that people 105 had negative feelings, such as disgust, towards overweight and obese people.12 There is also 106 new scientific evidence that estimates increases in weight gain and reductions in metabolic 107 rate due to weight stigma.6 Over the last 10 years, the United States has reported higher 108 numbers of weight discrimination in the past decade. Unfairness because of weight 109 stigmatisation has been reported in employment, educational, and even health care settings. 110 Employers have described multiple stereotypical attitudes against overweight and obese 111 workers, such as in hiring, salary levels, and receiving promotions. In 2006, a study 112 conducted in the United States of more than 2,000 participants reported that 25% of those of 113 heavy weight had faced job discrimination.6 Furthermore, another study showed that more 114 than half (54%) of employees were subject to weight stigmatisation from their colleagues at 115 work, and 43% reported stigmatisation from their supervisors because of their weight. 116 117 In healthcare settings, patients who are obese or overweight can also be affected by situations 118 that involve a weight bias. In addition, negative attitudes from health care professionals, such 119 as physicians, nurses, psychologists, and medical students, towards their obese patients have 120 been registered. They have commonly stereotyped obese patients as lazy, uncommitted, and 121 lacking the power to control their weight.6 122 123 Research on educational environments regarding this topic is less prominent than what has 124 been conducted in healthcare and employment environments. Students who are overweight or 125 obese in educational settings are often stigmatised by their peers, teachers, or even their 126 parents.6 A nationwide study in Saudi Arabia that included 4,709 participants revealed that 127 the stigmatisation of obesity prevalence is 46.4%.13.Another study including 1,459 128 participants found that obese people in Saudi Arabia face stigmatisation that is manifested in 129 different forms, including primarily negative behaviours (25.6%), bad comments (25.4%), 130 and physical barriers (25.2%).14 Interestingly, Khodari, et al. 15 recently explored weight self-131 stigma in Jazan (in the Southern Region of Saudi Arabia) and demonstrated that it was 132 positively associated with BMI. 133 134 The attribution value model was developed by Weiner 16 and may provide a plausible 135 explanation of stigmatisation towards a given person or group of people. Weiner 17 suggested 136 that antipathy towards a specific group is the result of believing that this specific group can 137 control their own behaviours. In the context of those who are overweight and obese, evidence 138 has confirmed that weight stigma has increased rates of association with attributions of trying 139 to control a person’s weight.18 Attribution theory tries to explain why people behave in a 140 certain way against a specific group based on their perceptions of the controllability of that 141 group.17 To manage the problem of the obesity epidemic, it is obligatory to address this other 142 aspect of the epidemic, which is weight stigma attitudes.8 Indeed, when stigmatisation is 143 decreased, it will improve the overall quality of life and minimise mental health issues among 144 obese people by removing stereotypes, discrimination, and prejudices. 145 146 The existing literature regarding the stigmatisation of obesity in SA is scarce, mainly 147 focusing on body image and preferences and the effect of stigma. This is a limitation, even if 148 obesity as a public health problem is exhaustively investigated in SA. The present study’s 149 uniqueness comes from its attempt to understand the root cause of stigmatisation by using the 150 attribution-value model to assess obesity stigma and its relation to a perception of 151 controllability. Our hypothesis is that there will be a significant association between 152 stigmatisation of obesity and perception of controllability among the general population in 153 Riyadh City. 154 155 Methods 156 This cross-sectional analytical study was carried out in Riyadh City (SA) during January–157 February 2021. Inclusion criteria included Saudi and non-Saudi individuals of both genders 158 who were residents of Riyadh City and 18 years old and above. A non-probability, 159 convenient sampling technique was used. A brief introduction about the aim of the research 160 and the target population, along with a link to the first page of the electronic questionnaire, 161 was distributed through social media applications, such as WhatsApp and Telegram. The 162 sample size was calculated manually with a 95% confidence interval multiplied by a design 163 effect of one. The prevalence of stigma was estimated to be 50%, and the total population 164 under study was above 10,000. After adding 10% to account for any incomplete data, the 165 necessary sample size was calculated to be 422 participants. The actual collected sample was 166 533 participants; eight participants were excluded because they were under 18 years old. 167 168 The self-administrated online questionnaire was hosted by Microsoft Forms, which was used 169 for data collection. The questionnaire was distributed in both the Arabic and English 170 languages. The questionnaire was developed and validated as described later, guided by the 171 Obese Stereotypes and Causes of Obesity Scale14 and the Anti-fat Attitudes Test 172 (AFAT).15The tool consisted of three sections. The first section included nine questions about 173 sociodemographic characteristics: gender, age, nationality, level of education, marital status, 174 monthly income, workplace, height (m), and body weight (kg). The last two were used for 175 body mass index (BMI) calculations. Participants were then categorised based on the WHO 176 guidelines16: Underweight, <18.50 kg/m2; Normal, 18.50–24.99 kg/m2; Overweight ≥25.00 177 kg/m2; and Obese ≥30.00 kg/m2. The BMI could not be calculated for 14 of the participants, 178 as they did not provide the required information. 179 180 The second section assessed obesity stereotypes and social, character, physical and romantic, 181 and attractiveness aspects, along with weight control. It consisted of 20 questions, which 182 were assessed based on a five-point Likert scale. The highest score of 5 was given to 183 “strongly agree”, and the lowest of 1 was given to “strongly disagree”. One question was 184 scored in reverse (“obese people are just as competent in their work as anyone else”). by 185 which a score of 1 was given to “strongly agree” and a score of 5 to “strongly disagree”. The 186 highest possible score was 100, and the lowest was 20. Data were interpreted based on 187 percentages in which respondents with scores between 20.0 and 46.6 were categorised as 188 having low stigma. Respondents who scored 46.7 to 73.3 were categorised as having 189 moderate stigma. Finally, those who scored 73.4 or higher were categorised as having a high 190 level of stigma. 191 192 The last section assessed the controllability of obese individuals. It consisted of six questions, 193 which were assessed based on a five-point Likert scale. The first three questions were scored 194 with 5 as “strongly agree”, and 5 as “strongly disagree”. The last three questions were 195 reversed: “strongly agree” was scored as 1, and “strongly disagree” was scored as 5. The 196 highest possible score for this section was 15. and the lowest was 3. The scores were divided 197 into high, moderate, and low levels of controllability. Respondents with a score between 3 198 and 6 were categorised as having low levels of controllability. Respondents who scored 7 to 199 10 were categorised as having moderate levels of controllability, and those with scores of 11 200 to 15 were categorised as having high levels of controllability. 201 202 A pilot study was planned to include 10% of the estimated sample size, which was 43 203 individuals; it was actually completed by a group of 45 residents of Riyadh. The pilot took 204 place in January 2021 to test the clarity and feasibility of the questionnaire. Three questions 205 were reported to be vague by the pilot participants, and they were modified for clarity. The 206 face validity was tested in terms of layout, feasibility, and the clarity of wording. Moreover, 207 the questionnaire was validated by experts in the fields of nutrition and public health. 208 Reliability was assessed using Cronbach’s alpha. Test section two showed high reliability 209 with a score of α = .8500. Section three showed acceptable reliability with α = .6519 after 210 excluding three questions. 211 212 The data were coded and analysed using JMP, Version 16.0.0 (SAS Institute Inc., Cary, NC, 213 1989-2021). Descriptive data are presented in frequency tables as numbers and percentages. 214 The data were analysed according to the type of measure; categorical variables were 215 presented in frequency tables and graphs. Associations between two categorical data 216 variables were tested using the chi-square test of two independent samples. A P-value <0.05 217 was considered as the cut-off point for significance. 218 219 Ethical approval was obtained from the Institutional Review Board (IRB) at xxx (Number 220 xxx). The research was performed in accordance with relevant guidelines/regulations. 221 Informed consent was confirmed on the first page of the questionnaire before the respondents 222 answered any part of the questionnaire. Participation in the research was voluntary, the data 223 were confidential, and there was no expected harm or risk to the participants. 224 225 Results 226 Table 1 summarises the characteristics of the study sample (N = 525). Female participants 227 represented 62.7% of the study sample. Participants aged 18–28 years constituted 41.9 % of 228 the sample. Most of the participants were Saudis (95.8%), and almost half were married 229 (53.0%). In terms of education and employment, 68.6 % reported that they had a bachelor’s 230 degree, and 37.3% were unemployed. As for monthly income, 47.6% reported earning less 231 than 8,000 SAR. Finally, based on the height and weight values provided by the respondents, 232 the BMI values were calculated for 510 individuals. More than half were either overweight or 233 obese (33.1% and 24.7 %, respectively). More than one-third had a normal BMI (36.9%), and 234 only 5.1% were underweight. 235 236 Table 2 shows that most of the participants had a low level of stigma (72.8%) and only two 237 participants showed high level of stigma (.04%). Slightly more than half (51.8%) and more 238 than one-third (35.4%) of the participants had moderate or high levels of perception of 239 controllable factors towards obesity, respectively. 240 241 Table 3 displays the association between the level of stigma towards obesity and the 242 sociodemographic characteristics of the studied sample. As the category of high 243 stigmatisation was of only shown in 0.4% of the sample which does not provide good 244 implications about the study analysis capability. A category of moderate to high was created 245 and the associations were calculated for two categories. Characteristics which are 246 significantly associated with stigma are gender (p = .0023) and BMI (p = .0360). 247 248 Table 4 shows that more than half of the participants who had a high level of perception 249 regarding controllability also had a low level of stigma. There was a significant association 250 between the perception of controllable factors and the level of stigma (p = .0001). 251 252 Table 5 displays a multivariate logistic regression to assess which factors successfully predict 253 intention. Being a female was a negative predictor of stigma while being overweight and with 254 high perception of controllability positively predicted stigma. 255 256 Discussion 257 This study assessed the stigmatisation of obesity and its relation to the perception of 258 controllability among a sample from the general population in Riyadh City. The research 259 findings support the hypothesis, as there was a significant association (p = .0001) between 260 stigmatisation of obesity and perception of controllability. Slightly less than one-third of the 261 participants had moderate stigma, and most of the participants demonstrated a low level of 262 stigma. This result is in concordance with previous findings showing that weight stigma of a 263 mild form was observed among the general public in Riyadh.19 264 265 In the United States over the past decade, discrimination regarding obesity has increased by 266 approximately 66% compared to other forms of discrimination, such as those related to 267 race.20 This can be attributed to the fact that weight stigma is often considered normal 268 behaviour in society. Also, some people think that it is humorous and acceptable to share 269 jokes about obese individuals. Moreover, TV and other media often present negative 270 stereotypes about obese individuals, such as they are lazy and irresponsible.14 271 272 The present study confirms that gender had a significant relationship with stigma, in which 273 males showed more stigma towards obesity compared to females. In fact, the multiple logistic 274 regression model showed that being female is a negative predictor of stigma. In agreement 275 with the current study’s finding, Flint, et al. 21 reported that males had significantly more 276 stigma towards obesity than females in the UK (p < 0.05). Similarly, Turkish male university 277 students had a higher stigma towards obese people compared to females.22 Taken together, 278 this result might be attributed to societal pressures that females face regarding how a female 279 body shape should look, which affects their emotions; thus, females tend to be more caring of 280 others’ feelings when it comes to physical appearance.23 This study showed that 44.2% of 281 those with low stigma were in the age range of 18–28 years. This could be explained by the 282 fact that this young age group tends to be more knowledgeable about the negative effects of 283 the stigmatisation of obese people. However, these findings are different from those 284 demonstrated by Jackson, et al. 24, which indicated that younger age groups have higher rates 285 of weight discrimination. 286 287 This study found that BMI was significantly associated with stigma (p=0.0360) in which 288 being overweight specifically positively predicted stigma. 38.6% of those with moderate to 289 high stigma were of normal weight and 39.3% of those with moderate stigma were 290 overweight; only 20.7% of those with moderate stigma were obese. A study conducted in the 291 United Kingdom found that individuals who were underweight or overweight had higher 292 stigmatisation rates than other BMI groups.21 293 294 According to the results of the present study, 20.6% of the participants had a high perception 295 of controllability regarding obesity and a low obesity stigma. In addition, the level of stigma 296 was significantly associated with the perceptions of controllability regarding obesity. The 297 multiple logistic regression model found that being overweight was a positive predictor of 298 stigma. This could be explained by attribution theory, which discusses how weight stigma 299 increases when the factors are controllable and decreases when the factors are 300 uncontrollable.18 This result supports the study published by Khan, et al. 25 These authors 301 revealed that when people know that the cause of obesity contains uncontrollable factors, 302 such as genetics, they express low stigma and are highly empathetic towards obese people. 303 However, when they know that the cause contains controllable factors, such as behaviour, 304 they highly express stigma and have low empathy towards obese people. 305 306 The strength of this study is that it is theoretically based. In terms of limitations, as the 307 sampling technique was based on a non-probability convenience technique, the results may 308 not be generalisable, although the study findings are of importance, as they provide an 309 explanation of one of the root causes of obesity stigmatisation. Another limitation of the 310 study could be the self-reporting of anthropometric measurements by the participants, which 311 could affect the accuracy of BMI categorisation. However, Allison, et al. 26 indicated that the 312 categorisation of BMI based on such values was more precise than using continuous values of 313 BMI when self-reported measures are used in health-related interventions. This was the case 314 in our study. 315 316 Conclusion 317 In conclusion, this research supported the hypothesis stating that there was a significant 318 association between stigmatisation of obesity and a perception of controllability among the 319 general population in Riyadh City, based on this particular sample. As for recommendations, 320 the authors suggest that they should be based on joint international consensus statements for 321 ending the stigma of obesity 27 in different settings and categories. At the research level, 322 conducting additional research in other cities in SA can provide a more holistic insight into 323 whether stigmatisation possibly influences obese people. At the community level, it is highly 324 recommended to establish strong policies that set a primary goal of filling the gap between 325 public health efforts and the general population regarding settings in which weight 326 discrimination occurs, such as healthcare, education, and workplaces. For example, in 327 healthcare settings, individuals who are trained to treat obese people should be concerned and 328 encourage them to seek medical help and also shift their attributions in messages from 329 focusing solely on diet and exercise (“calories in and calories out”) that can be controllable 330 factors for people to include other attributions that can be uncontrollable. It is important to 331 understand the etiology of obesity rather than just the traditional approach to obesity 332 management. 333 334 Conflicts of Interest 335 The authors declare no conflict of interests. 336 337 Funding 338 No funding was received for this study. 339 340 Author Contributions 341 All authors substantially contributed to the design of the study. NF, SAA and SHA collected 342 the data, performed the statistical analysis and literature review. All authors participated in 343 the interpretation of the results and drafting the manuscript. FA, NB and MA revised the 344 manuscript and edited the English. All authors approved the final version of the manuscript. 345 346 References 347 1. Memish, Z. A., El Bcheraoui, C., Tuffaha, M., Robinson, M., Daoud, F., Jaber, S., et al. 348 Peer reviewed: obesity and associated factors—Kingdom of Saudi Arabia, 2013. 349 Preventing chronic disease; 2014; 11: 350 2. WHO. Obesity. From: https://www.who.int/health-topics/obesity#tab=tab_1 Accessed: 351 3-1-2022 352 3. Al-Shehri, F. S., Moqbel, M. M., Al-Khaldi, Y. M., Al-Shahrani, A. M., Abu-Melha, W. 353 S., Alqahtani, A. R., et al. Prevention and management of obesity: Saudi guideline 354 update. Saudi Journal of Obesity; 2016; 4: 25. 355 4. Waxman, A. WHO Global Strategy on Diet, Physical Activity and Health. Food and 356 Nutrition Bulletin; 2004; 25: 292-93. 357 5. Obesity. From: https://www.mayoclinic.org/diseases-conditions/obesity/symptoms-358 causes/syc-20375742 Accessed: 3-1-2022 359 6. Puhl, R. M. and Heuer, C. A. 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Perceived weight 408 discrimination in England: a population-based study of adults aged⩾ 50 years. 409 International journal of obesity; 2015; 39: 858-64. 410 25. Khan, S. S., Tarrant, M., Weston, D., Shah, P. and Farrow, C. Can raising awareness 411 about the psychological causes of obesity reduce obesity stigma? Health communication; 412 2018; 33: 585-92. 413 26. Allison, C., Colby, S., Opoku-Acheampong, A., Kidd, T., Kattelmann, K., Olfert, M. D., 414 et al. Accuracy of self-reported BMI using objective measurement in high school 415 students. J Nutr Sci; 2020; 9: e35. 10.1017/jns.2020.28 416 27. Rubino, F., Puhl, R. M., Cummings, D. E., Eckel, R. H., Ryan, D. H., Mechanick, J. I., et 417 al. Joint international consensus statement for ending stigma of obesity. Nature Medicine; 418 2020; 26: 485-97. 10.1038/s41591-020-0803-x 419 Table 1: Sociodemographic characteristics of the studied sample (n = 525) 420 Sociodemographic characteristics N (%) Gender Female Male 329 (62.7) 196 (37.3) Age (years) 18–28 29–39 40 and above 220 (41.9) 156 (29.7) 149 (28.4) Nationality Saudi Non-Saudi 503 (95.8) 22 (4.2) Marital status Married Not married 278 (53.0) 247 (47.0) Level of education Less than high school High school or diploma Bachelor's degree Higher education 16 (3.0) 87 (16.6) 360 (68.6) 62 (11.8) Workplace Unemployed Government sector Private sector Freelance Retired 196 (37.3) 165 (31.4) 120 (22.9) 13 (2.5) 31 (5.9) Monthly income (SAR) < 8,000 8,000–16,000 > 16,000 250 (47.6) 180 (34.3) 95 (18.1) BMI categories (n = 510) Underweight Normal weight Overweight Obese 26 (5.1) 188 (36.9) 170 (33.3) 126 (24.7) SAR = Saudi Riyals, 421 BMI categories: Underweight, <18.50 kg/m2; Normal, 18.50–24.99 kg/m2; Overweight 422 ≥25.00 kg/m2; and Obese ≥30.00 kg/m2 423 424 Table 2: Level of stigma and controllability toward obesity in the studied sample (n = 425 525) 426 N (%) Level of stigma (score range) Low (20.0–46.6) 382 (72.8) Moderate (46.7–73.3) 141(26.9) High (73.4–100.0) 2 (0.4) Level of controllability (score range) Low (3–6) 67 (12.8) Moderate (7–10) 272 (51.8) High (11–15) 186 (35.4) 427 Table 3: Association between level of stigma toward obesity and sociodemographic 428 characteristics of the studied sample (n = 525) 429 Level of stigma Low (n = 382) N (%) Moderate to high (n = 143) N (% ) P-value Gender Male Female 127 (33.3) 255 (66.8) 74 (51.8) 69 (48.3) 0.0023* Age (Years) 18–28 29–39 40 and above 169 (44.2) 106 (27.8) 107 (28.0) 51 (36.2) 50 (35.0) 42 (29.4) 0.1558 Nationality Saudi Non-Saudi 366 (95.8) 16 (4.2) 137 (95.8) 6 (4.2) 0.1487 Marital status Married Not married 200 (52.4) 182 (47.6) 78 (54.6) 65 (45.5) 0.6948 Level of education Less than high school High school/diploma Bachelor’s degree Higher education 12 (3.1) 62 (16.2) 263 (68.8) 45 (11.8) 4 (2.8) 25 (17.5) 97 (67.8) 17 (11.9) 0.9844 Workplace Unemployed Government sector Private sector Freelance Retired 151 (39.5) 117 (30.6) 84 (22.0) 7 (1.8) 23 (6.0) 45 (31.5) 48 (33.6) 36 (25.2) 6 (4.2) 8 (5.6) 0.2938 Monthly income (SAR) < 8,000 8,000–16,000 > 16,000 185 (48.4) 129 (33.8) 68 (17.8) 65 (45.5) 51 (35.7) 27 (18.9) 0.3372 BMI cat. (n = 510) Underweight Normal weight Overweight Obese (n = 370) 24 (6.5) 134 (36.2) 115 (31.1) 97 (26.2) (n = 138) 2 (1.4) 54 (38.6) 52 (39.3) 28 (20.7) 0.0360* SAR = Saudi Riyals 430 BMI categories: Underweight, <18.50 kg/m2; Normal, 18.50–24.99 kg/m2; Overweight 431 ≥25.00 kg/m2; and Obese ≥30.00 kg/m2 432 P-value is calculated using the chi2 test. 433 434 Table 4: Association between stigmatisation level and its relation to perception of 435 controllability (n = 525) 436 Level of controllability Level of stigmatisation of obesity P-value Low Moderate to high Low 59 (15.5) 8 (5.6) 0.0001* Moderate 215 (56.3) 57 (39.9) High 108 (20.6) 78 (54.6) Total 382 (72.8) 143 (26.9) P-value is calculated using the chi2 test. 437 438 Table 5: Multiple logistic regression with Gender, nationality, BMI, and controllability 439 Parameter estimates Term Estimate Std Error ChiSquare Prob>ChiSq Intercept -1.5291252 0.3361126 20.07 <.0001* Gender Female -0.2397304 0.1066013 5.06 0.0245* Nationality Saudi 0.04284096 0.2654482 0.03 0.8718 BMI Normal weight 0.42743278 0.2358471 3.28 0.0699 Overweight 0.53475875 0.2387129 5.02 0.0251* Obese 0.11420282 0.2561442 0.20 0.6557 Controllability Low -0.7423099 0.2635433 7.93 0.0049* High 0.85041049 0.1707867 24.79 <.0001* 440