Abstract
Background
Weight stigma, a pervasive public health concern, is characterized by negative attitudes, prejudices, and stereotypes directed towards individuals with larger body sizes. Empirical evidence indicates a significant association between experiencing weight stigma and adverse psychological health outcomes, including body image dissatisfaction, eating disorders, and increased risk of depression, anxiety, self-harm, and suicidal ideation. Acceptance and Commitment Therapy (ACT), a third-wave behavioral approach, shows potential in reducing weight stigma by targeting psychological flexibility and values-based action. However, current evidence remains limited and fragmented, often neglecting the complex, multidimensional nature of weight stigma. Therefore, this review aims to synthesize and evaluate existing evidence on the effectiveness of ACT in reducing weight stigma and improving related psychological outcomes. Additionally, we will identify the specific content and delivery features of effective ACT interventions targeting weight stigma.
Methods
We will conduct a comprehensive search of electronic databases, including PubMed, Embase, Web of Science, Scopus, CINAHL, and the Cochrane Library. The Association for Contextual Behavioral Science (ACBS) website will be searched to identify summaries of randomized controlled trials and Google Scholar will be utilized to identify relevant grey literature. Only original research articles published in English from 1994 to 2025 will be included, and the database searches will be updated prior to final manuscript submission to capture the most recent evidence. Screening, data extraction and quality assessment will be conducted independently by the primary reviewer and the second reviewer. Any inconsistencies will be addressed through discussion with a third reviewer. If substantial heterogeneity (I2 > 75%) or insufficient comparable data precludes meta-analysis, findings will be synthesized narratively.
Discussion
This systematic review will synthesize the extant literature on the effectiveness of ACT, encompassing its contents and delivery features in reducing weight stigma and improving related psychological outcomes among individuals experiencing weight-related stigmatization. The evidence generated from this review has the potential to inform public health initiatives, shape future intervention research, and contribute to broader efforts to mitigate the harmful impact of weight stigma on individual and societal levels.
Systematic review registration
PROSPERO CRD420251121507
Supplementary Information
The online version contains supplementary material available at 10.1186/s13643-026-03205-x.
Keywords: Acceptance and Commitment Therapy, Weight stigma, Psychological outcomes, Systematic review protocol
Background
Overweight and obesity, as chronic metabolic disorders, have been increasing rapidly worldwide in recent years, posing a serious threat to public health [1]. These conditions are frequently accompanied by significant weight stigma [2], characterised by negative attitudes, prejudices, and stereotypes toward individuals with larger body sizes. Recognised as a socially accepted and pervasive form of stigma [3], weight stigma spans individual, interpersonal, institutional, and societal levels, manifesting in workplaces, healthcare settings, educational environments, and the media. In the United States, the prevalence of weight stigma increased by 66% over a decade, surpassing the rise observed for racial discrimination during the same period [4]. Such stigma leads to social devaluation and discriminatory behaviours, with individuals often labelled as “mean, stupid, ugly, unfortunate, less capable, socially marginalised, lacking self-discipline, and lacking self-control” [5]. Conceptually, weight stigma can be categorised as external (public stigma) or internal (weight bias internalisation or self-stigma) [6]. External stigma encompasses societal prejudice, stereotyping, and discrimination, whereas internal stigma reflects the extent to which individuals endorse and apply these societal weight-based stereotypes to themselves [7, 8].
Weight stigma is a significant contributor to poor health outcomes. The Lancet-Healthy Longevity 2025 [9] states that more than 1.9 billion people globally face weight stigma. This stigma is not only detrimental to mental health, but is also associated with a 23% increase in all-cause mortality and a 7.5-year reduction in healthy life expectancy. Tomiyama (2014) [10] developed the Cyclic Obesity/Weight-Based Stigma Model (COBWEBS), defining weight stigma as an experience that triggers predictable negative emotions, which in turn lead to weight gain or hinder weight loss. This cycle operates through altered eating behaviours and increased cortisol levels, exposing individuals to further stigma and sustaining the vicious cycle. A large meta-analysis combining 105 studies (including data from more than 59,000 participants) proved that individual-perceived weight stigma was significantly associated with poorer mental health, such as body image dissatisfaction, reduced quality of life, eating dysfunction, depression and anxiety [11]. Furthermore, individuals who experience weight stigma are more likely to avoid healthcare-seeking behaviours [12], thus perpetuating psychological problems associated with obesity and weight stigma [13]. Notably, such stigma experiences significantly raise the risk of self-harm and suicidal behaviour; for example, adolescents exposed to weight stigma are approximately twice as likely to engage in self-harm or suicidal behaviours [14].
To address psychological distress related to weight stigma [15], psychological interventions targeting weight-related concerns are essential [16]. Acceptance and Commitment Therapy (ACT), a third-generation cognitive-behavioural therapy [17, 18], has emerged as a promising intervention for addressing weight stigma and associated psychological distress [19]. Second-generation therapies such as Cognitive Behavioral Therapy (CBT) are commonly recommended for weight loss and binge-eating reduction [19], and have demonstrated effectiveness in certain contexts [20, 21]. However, evidence regarding their long-term efficacy in sustaining weight loss and managing weight-related emotional distress remains mixed [22]. Importantly, CBT-based interventions vary widely in content, intensity, and delivery format, and outcomes may differ accordingly. While findings regarding CBT outcomes are mixed and may not apply uniformly across all CBT approaches [23], one study reported that 30–50% of individuals continue to experience overweight and binge-eating symptoms after CBT interventions, often accompanied by further weight gain and diminished quality of life [24]. In contrast, ACT does not directly target obesity symptoms but instead aims to alleviate obesity-related psychological difficulties, thereby supporting positive behaviours such as physical activity and dietary regulation [19]. By enhancing awareness, acceptance, and regulation of binge-eating urges [25], ACT may offer complementary advantages in reducing social stigma and improving weight management.
However, existing reviews have primarily focused on the role of ACT in general weight management or obesity-related outcomes [24, 26], with minimal attention given to weight stigma as a distinct psychosocial issue. To date, only one systematic review, published in 2018 [27], has examined the effects of ACT on body dissatisfaction and weight self-stigma. However, this review did not address the broader spectrum of weight stigma, including experienced, perceived, internalised, and anticipated forms [28]. Moreover, the available evidence was methodologically constrained by small sample sizes and low-quality studies, resulting in inconclusive findings regarding ACT’s effectiveness in this context [27]. The present review therefore aims to both update the 2018 synthesis and expand its scope by incorporating broader conceptualisations of weight stigma and more recent empirical evidence. Given the psychological and behavioural consequences of weight stigma and the growing global interest in value-based, acceptance-oriented interventions, a comprehensive and up-to-date synthesis is warranted to assess ACT’s effectiveness across multiple forms of weight stigma [20, 29].
To address the above-described knowledge gap, the primary aim of this systematic review is to evaluate the effectiveness of ACT in addressing weight stigma and related psychological outcomes. The secondary aim is to examine the contents and delivery features of effective ACT interventions. Our results will be beneficial to the dissemination of evidence and improvement of physical and mental health.
Methods
Protocol and registration
The systematic review protocol was registered in PROSPERO (registration number CRD420251121507) and formulated in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) guidelines [30, 31] (Additional file 1). The subsequent systematic review will be executed in compliance with the PRISMA statement [32].
Eligibility criteria
The PICOS framework (Population, Intervention, Comparison, Outcome, and Study Design) will be employed to define the inclusion criteria (Table 1) for this systematic review protocol. Only original research articles published in English in peer-reviewed journals will be considered. Abstracts, reviews, protocols, editorials, letters, conference proceedings, book chapters, clinical correspondence, and case reports will be excluded.
Table 1.
Eligibility criteria of this study
| PICOS | Eligibility criteria |
|---|---|
| P | Participants who have experienced, perceived, internalized, anticipated, and/or self-directed weight stigma |
| I |
• Intervention based on Acceptance and Commitment Therapy (delivered individually or in a group; via single or multiple sessions; by any provider, including fully-digitized interventions or face-to-face modality or mixed delivery format; in any setting) • Studies implemented Acceptance and Commitment Therapy as an independent or a major part of intervention (the number of Acceptance and Commitment Therapy hours was more than 50% of total therapy hours) |
| C |
• Waitlisted or no treatment • Usual care or attention control • Placebo control • Alternative treatment (nonpharmacological intervention) or other therapies |
| O |
• Primary outcomes: External weight stigma and internal weight stigma • Secondary outcomes: Weight stigma related psychological outcomes (e.g., psychological flexibility, disordered eating behaviors, body image dissatisfaction, and negative emotions such as anxiety, depression, stress, etc.) |
| S |
Experimental studies, including: • Randomized controlled trials (including pilot randomized controlled trials) • Quasi-experimental studies (e.g., non/equivalent control group design, single group, pre-test/post-test, or before after design) |
When determining whether ACT comprises more than 50% of an intervention, detailed descriptions of intervention components will be examined, including published protocols, supplementary materials, and trial registrations where available. If the proportion of ACT content is unclear, corresponding authors will be contacted for clarification. Where sufficient information cannot be obtained, the study will be excluded, and the reason documented.
Information sources and search strategy
We will conduct a comprehensive search for relevant studies across six electronic databases: PubMed, Embase, Web of Science, Scopus, CINAHL, and the Cochrane Library. Furthermore, we will refer to the Association of Contextual Behavioral Science (ACBS) (https://contextualscience.org/) for a summary of randomized controlled trials (RCTs) on ACT. Additionally, Google Scholar will be used to identify grey literature. Only studies published in English will be included. The search period will commence from 1994 to 2025, as this marks the first appearance of the term Acceptance and Commitment Therapy in the published literature [33]. The database searches will be updated prior to final manuscript submission to capture the most recent publications. The search strategy was initially developed by FFC and QYW, in collaboration with a librarian, following the PICOS framework to ensure broad and thorough retrieval of relevant studies.
The search strategy will employ Medical Subject Headings (MeSH), keywords, Boolean operators, and wildcards to capture variations and synonyms for “Weight Prejudice” and “Acceptance and Commitment Therapy” across databases. It will also integrate terms derived from existing systematic reviews and relevant studies on weight stigma and ACT. A preliminary search will be conducted in PubMed, with the draft search strategy provided in Table 2. Two reviewers (FFC and QYW) will independently assess 50 randomly selected records each against predefined eligibility criteria, and these records will also be reviewed to identify further relevant terms, allowing refinement of the search strategy.
Table 2.
Search strategy in PubMed
| Number | Search Terms |
|---|---|
| #1 | “weight prejudice”[MeSH Terms] |
| #2 | “weight prejudice”[Title/Abstract] OR “fat bias”[Title/Abstract] OR “obesity bias”[Title/Abstract] OR “fatphobia*”[Title/Abstract] OR “fat phobia”[Title/Abstract] OR “fat phobias”[Title/Abstract] OR “anti-fat bias”[Title/Abstract] OR “anti-fat bias”[Title/Abstract] OR “weight-bias”[Title/Abstract] OR “weight-bias”[Title/Abstract] OR “weight-stigma”[Title/Abstract] OR “weight-stigma”[Title/Abstract] OR “weight stigmas”[Title/Abstract] OR “weight-based discrimination”[Title/Abstract] OR “weight-based discrimination”[Title/Abstract] OR “weight-based discriminations”[Title/Abstract] OR “fat shaming”[Title/Abstract] OR “weight stigmatisation”[Title/Abstract] OR “weight stigmatization”[Title/Abstract] OR “sizeism”[Title/Abstract] OR “weightism”[Title/Abstract] OR “weight victimization”[Title/Abstract] OR “weight discrimination”[Title/Abstract] OR “weight bullying”[Title/Abstract] OR “weight teasing”[Title/Abstract] |
| #3 | “body weight”[MeSH Terms] OR “weight gain”[MeSH Terms] OR “overweight”[MeSH Terms] OR “obesity”[MeSH Terms] |
| #4 | “weight”[Title/Abstract] OR “obesity”[Title/Abstract] OR “overweight”[Title/Abstract] OR “over-weight”[Title/Abstract] OR “body weight”[Title/Abstract] OR “body mass index”[Title/Abstract] OR “bmi”[Title/Abstract] OR “weight-related”[Title/Abstract] OR “weight gain”[Title/Abstract] OR “fat”[Title/Abstract] OR “heavy”[Title/Abstract] OR “body”[Title/Abstract] OR “larger body”[Title/Abstract] OR “body size”[Title/Abstract] OR “adiposity”[Title/Abstract] OR “fatness”[Title/Abstract] OR “body shape”[Title/Abstract] OR “weight-based”[Title/Abstract] |
| #5 | (#3) OR (#4) |
| #6 | “social stigma”[MeSH Terms] OR “violence”[MeSH Terms] OR “bullying”[MeSH Terms] |
| #7 | “stigma*”[Title/Abstract] OR “social stigma”[Title/Abstract] OR “discriminat*”[Title/Abstract] OR “social discrimination”[Title/Abstract] OR “prejudic*”[Title/Abstract] OR “stereotyp*”[Title/Abstract] OR “sham*”[Title/Abstract] OR “bully*”[Title/Abstract] OR “bias*”[Title/Abstract] OR “blam*”[Title/Abstract] OR “implicit attitude”[Title/Abstract] OR “explicit attitude”[Title/Abstract] OR “stereotype”[Title/Abstract] OR “teas*”[Title/Abstract] OR “disgust*”[Title/Abstract] OR “unfair treatment”[Title/Abstract] OR “victim*”[Title/Abstract] OR “harass*”[Title/Abstract] OR “social isolation”[Title/Abstract] OR “unfair*”[Title/Abstract] OR “intoleranc*”[Title/Abstract] OR “social exclusion”[Title/Abstract] OR “violen*”[Title/Abstract] |
| #8 | (#6) OR (#7) |
| #9 | (#5) AND (#8) |
| #10 | ((#1) OR (#2)) OR (#9) |
| #11 | “acceptance and commitment therapy”[All Fields] OR “acceptance and commitment”[All Fields] OR “acceptance commitment therap*”[All Fields] OR “acceptance commitment”[All Fields] OR “psychological flexibility”[All Fields] OR “psychological inflexibility”[All Fields] OR “acceptance-based”[All Fields] OR “commitment-based”[All Fields] OR “ACT-based”[All Fields] OR “ACT psychotherapy”[All Fields] |
| #12 | (#10) AND (#11) |
| #13 | (#10) AND (#11) AND (english[Filter]) |
| #14 | (#10) AND (#11) AND ((english[Filter]) AND (1994:2025[pdat])) |
Data management
The primary reviewer (FFC) and the second reviewer (QYW) will retrieve articles from online databases and manage references using EndNote (https://endnote.com/). After deduplication, records will be imported into Rayyan (https://www.rayyan.ai/) for screening and data extraction. Rayyan will be used to track screening decisions and to generate the PRISMA flow diagram. Customized data extraction forms will be developed within the software, and all relevant data will be extracted directly into Rayyan. Title and abstract screening and full-text review will be conducted collaboratively by two reviewers, with both independently applying the eligibility criteria. Discrepancies will be resolved through discussion with a third reviewer (MS) to reach consensus. Only studies meeting inclusion criteria will be retained for data extraction.
Data extraction
The research team will construct a data extraction form. To assess the form’s usability, a pilot test will be performed using a random sample of five studies. Data extraction will be performed independently by two reviewers (FFC and QYW). The extracted data will encompass study characteristics, including publication details, study information, participant characteristics, intervention characteristics and outcomes (Table 3). Regular meetings will be scheduled throughout this phase. Discrepancies between the two reviewers will be resolved through consensus; if consensus cannot be reached, a third reviewer (MS) will adjudicate to make a final determination. Moreover, the data extraction process will be iterative, allowing for the inclusion, modification, or exclusion of extraction elements as deemed necessary by the team.
Table 3.
Data to be extracted from studies
| Domain | Data |
|---|---|
| Publication characteristics | First authors, year, country, and study design |
| Participant characteristics | Age, sample size, and gender |
| Measurement | Instruments, timing of assessments |
| Intervention characteristics | Content, dose, duration, delivery type, setting, completion rate, and control group intervention |
| Outcomes | Weight stigma and related psychological outcomes (e.g., psychological flexibility, disordered eating behaviors, body image dissatisfaction, and negative emotions such as anxiety, depression, stress, etc.) |
Risk of bias in individual studies
The methodological rigor and risk of bias of each included study will be independently assessed by two reviewers (FFC and QYW). Discrepancies will be resolved through discussion with a third reviewer (MS). For randomized-controlled trials, the Cochrane Risk of Bias tool for randomized trials (RoB 2) will be used to evaluate potential bias arising from the randomization process, deviations from intended interventions, missing outcome data, measurement of the outcome, and selection of the reported result [34]. The RoB2 assessments within each domain will be categorized as low risk, some concerns, and high risk [34]. For the included non-randomized studies, the Risk of Bias in Non-Randomized Studies of Interventions (ROBINS-I) tool will be used to assess potential biases arising from confounding, classification of interventions, selection of participants into the study, deviations from intended interventions, missing data, measurement of the outcome, selection of the reported result, and overall bias [35]. Risk of bias judgments for each ROBINS-I domain will be categorized as low risk, moderate risk, serious risk, critical risk, or no information [35]. Additionally, intervention fidelity will be assessed within the “other bias” domain of the RoB 2 tool for RCTs [34], and within the “deviations from intended interventions” domain of ROBINS-I [35].
Data synthesis and analysis
Review Manager (RevMan 5.4) will be used to analyse extracted data from included studies. Effect sizes will be calculated as odds ratios (ORs) for dichotomous outcomes and as weighted mean differences (MDs) or standardised mean differences (SMDs) for continuous outcomes, each with 95% confidence intervals (CIs). Interventions will be considered effective if they demonstrate statistically significant improvements in weight stigma outcomes and/or related psychological outcomes compared with control or baseline.
Given conceptual and measurement differences, external and internalised weight stigma outcomes will be synthesised separately. Meta-analyses will be conducted primarily for external weight stigma, internalised weight stigma, and weight stigma-related psychological outcomes (e.g., psychological flexibility, disordered eating behaviours, body image dissatisfaction, and negative emotions such as anxiety, depression, and stress) when assessed using comparable validated instruments and reported with sufficient statistical data [36]. Intervention content and delivery features (e.g., dose, duration, delivery type, and setting) will be synthesised narratively.
Meta-analysis will be conducted when sufficient data are available and clinical and methodological heterogeneity is considered acceptable. Statistical heterogeneity will be assessed using the χ2 (Q) test (with p ≤ 0.1 indicating statistical significance) and quantified using the I2 statistic, with thresholds of 25%, 50%, and 75% representing low, moderate, and high heterogeneity, respectively [36]. If p ≤ 0.1 and I2 > 50%, heterogeneity will be considered significant and a random-effects (RE) model will be applied. If p > 0.1 and I2 ≤ 50%, heterogeneity will be considered low and a fixed-effects (FE) model will be used [37]. Forest plots will be generated to present pooled estimates and corresponding 95% CIs. If substantial heterogeneity (I2 > 75%) or insufficient comparable data precludes meta-analysis, findings will be synthesised narratively. If effect estimates, standard deviations, sample sizes, or other statistical data required for meta-analysis are missing or insufficiently reported, the corresponding authors of the original studies will be contacted for clarification or additional information. Where possible, missing values will be calculated or estimated from available statistics according to recommended methodological guidance. Studies with insufficient data that cannot be resolved will be excluded from quantitative synthesis but retained in the narrative synthesis where appropriate.
Subgroup analyses will be performed, where sufficient data are available, to examine whether intervention effects differ according to study design (RCT vs. quasi-experimental), type of weight stigma (external vs. internalised), intervention components, delivery format (e.g., group vs. individual), duration, intensity, and setting. A statistician will be consulted prior to conducting subgroup analyses to ensure methodological appropriateness. Sensitivity analyses will be conducted to assess the robustness of pooled estimates.
Publication bias will be assessed using a funnel plot with Egger’s test if a meta-analysis includes 10 or more studies. Additional sensitivity analyses will be performed to evaluate the influence of methodological quality on the pooled estimates. We acknowledge that these methods have limited power when the number of included studies is small, and results will be interpreted with caution.
Confidence in cumulative evidence
The certainty of the evidence will be assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach [38]. A Summary of Findings (SoF) table will be generated using GRADEpro GDT (McMaster University, ON, Canada). Where applicable, the SoF table will include absolute risk estimates for both intervention and control groups, relative risk estimates, and an evaluation of evidence certainty based on risk of bias, directness, heterogeneity, precision, and publication bias. The primary outcome reported in the SoF table will be weight stigma scores.
Discussion
Weight stigma is increasingly recognized as a pervasive and harmful social phenomenon [1], contributing to psychological distress [11], barriers in healthcare engagement [12] and reduced overall well-being [13]. ACT has emerged as a promising intervention for addressing various physical and mental health conditions, including anxiety [39], depression [40], stress [41] and chronic pain [42]; however, its application to weight stigma remains underexplored. While one review has examined the effectiveness of ACT on weight self-stigma, its impact remains uncertain due to limitations in study quality and sample size [27]. Furthermore, the effectiveness of ACT on diverse manifestations of weight stigma is not well-established.
This systematic review aims to synthesise existing evidence on the effectiveness of ACT across multiple forms of weight stigma and related psychological outcomes, including psychological flexibility, disordered eating behaviors, body image dissatisfaction, and negative emotional states. Specifically, external weight stigma and internalized (self-)stigma will be considered separately, to clarify whether intervention effects differ by stigma type. Additionally, the review will identify the specific components and delivery features of ACT interventions that may contribute to their effectiveness.
The anticipated contributions of this review are threefold. First, it is expected to clarify how ACT interventions may influence external and internalized weight stigma and related psychological outcomes, providing a more precise evidence base for researchers and practitioners. Second, by examining intervention components and delivery modalities, the review may inform the development of more targeted, efficient, and scalable approaches to reducing weight stigma. Finally, the evidence generated is expected to support future intervention research, inform public health initiatives, and contribute to broader efforts aimed at mitigating the harmful impact of weight stigma on individuals and society.
Nevertheless, several potential limitations should be acknowledged. Heterogeneity in study populations, intervention characteristics, outcome measures, and delivery formats may limit the comparability of findings and pose challenges for meta-analytic synthesis. Restricting the review to English-language publications may introduce language bias and omit relevant studies published in other languages, thereby affecting the comprehensiveness and generalizability of the review findings. Additionally, interpretation of the findings may be constrained by potential under-reporting or variability in the measurement of weight stigma outcomes, as well as by small sample sizes and short follow-up periods in primary studies. Synthesizing evidence across diverse outcome measures may also present challenges in identifying consistent patterns of effectiveness. These limitations will be carefully considered when discussing the anticipated contributions of the review and their implications for future research and intervention development.
Supplementary Information
Acknowledgements
Not applicable
Abbreviations
- CBT
Cognitive Behavioral Therapy
- ACT
Acceptance and Commitment Therapy
- COBWEBS
Cyclic Obesity/Weight-Based Stigma Model
- PRISMA-P
Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols
- PICOS
Population, Intervention, Comparison, Outcome, and Study Design
- ACBS
Association of Contextual Behavioral Science
- RCTs
Randomized controlled trials
- MeSH
Medical Subject Headings
- RE
Random-effects
- FE
Fixed-effects
- RoB 2
Cochrane Risk of Bias tool for randomized trials
- ROBINS-I
Risk of Bias in Non-Randomized Studies of Interventions
- OR
Odds ratios
- MD
Mean differences
- CIs
Confidence intervals
- GRADE
Grading of Recommendations Assessment, Development and Evaluation
- SoF
Summary of findings
Authors’ contributions
Conceptualization: HW, FFC, and MS. Methodology developments: HW, FFC, XMT, and NH. Search strategy development: HW, FFC, and MS. PROSPERO submission: FFC. Database searches: FFC, and QYW. Writing initial draft: FFC. All authors read, provided feedbacks, and approved the final protocol.
Funding
This work was supported by [Guangzhou Concord Medical Humanities Research and Education Fund] grant number [23000–3050070].
Data availability
The search strategy and other materials are available from the corresponding author upon reasonable request.
Declarations
Ethics approval and consent to participate
Not applicable
Consent for publication
Not applicable
Competing interests
The authors declare that they have no competing interests.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The search strategy and other materials are available from the corresponding author upon reasonable request.