A Twitter Discourse Analysis of Negative Feelings and Stigma Related to NAFLD, NASH and Obesity

Jeffrey V. Lazarus; Christine Kakalou; Adam Palayew; Christina Karamanidou; Christos Maramis; Pantelis Natsiavas; Camila A Picchio; Marcela Villota-Rivas; Shira Zelber-Sagi; Patrizia Carrieri


Liver International. 2021;41(10):2295-2307. 

In This Article

Abstract and Introduction


Background: People with non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH) are stigmatized, partly since 'non-alcoholic' is in the name, but also because of obesity, which is a common condition in this group. Stigma is pervasive in social media and can contribute to poorer health outcomes. We examine how stigma and negative feelings concerning NAFLD/NASH and obesity manifest on Twitter.

Methods: Using a self-developed search terms index, we collected NAFLD/NASH tweets from May to October 2019 (Phase I). Because stigmatizing NAFLD/NASH tweets were limited, Phase II focused on obesity (November-December 2019). Via sentiment analysis, >5000 tweets were annotated as positive, neutral or negative and used to train machine learning–based Natural Language Processing software, applied to 193 747 randomly sampled tweets. All tweets collected were analysed.

Results: In Phase I, 16 835 tweets for NAFLD and 2376 for NASH were retrieved. Of the annotated NAFLD/NASH tweets, 97/1130 (8.6%) and 63/535 (11.8%), respectively, related to obesity and 13/1130 (1.2%) and 5/535 (0.9%), to stigma; they primarily focused on scientific discourse and unverified information. Of the 193 747 non-annotated obesity tweets (Phase II), the algorithm classified 40.0% as related to obesity, of which 85.2% were negative, 1.0% positive and 13.7% neutral.

Conclusions: NAFLD/NASH tweets mostly indicated an unmet information need and showed no clear signs of stigma. However, the negative content of obesity tweets was recurrent. As obesity-related stigma is associated with reduced care engagement and lifestyle modification, the main NAFLD/NASH treatment, stigma-reducing interventions in social media should be included in the liver health agenda.


Non-alcoholic fatty liver disease (NAFLD) is a highly prevalent, emerging illness[1,2] and the leading cause of chronic liver disease worldwide.[3] It is characterized by fat accumulation in the liver in the absence of elevated alcohol intake and other competing liver aetiologies, such as chronic viral hepatitis or the use of medications that induce steatosis.[2] NAFLD can progress to non-alcoholic steatohepatitis (NASH) and eventually to end-stage liver disease, liver cancer and death.[3,4] NAFLD is estimated to affect 25% of the global population and NASH affects up to around 20% of people with NAFLD;[2] however, reliable epidemiological estimates are scarce. NAFLD has been demonstrated to be related to an unhealthy diet and sedentary lifestyle and is strongly associated with obesity, with the prevalence increasing proportionally with increases in body mass index.[5] The estimated prevalence of NAFLD in people with obesity is 58%-74%[6–8] and lifestyle modification alongside weight reduction is currently the only established treatment.[9]

However, lifestyle modification and weight loss can be challenging, and even more so when stigma and discrimination are involved since they increase patients' psychological burden, particularly among women and children.[10,11] Stigma towards NAFLD/NASH may be related to two major causes: one is liver disease related, partly in relation to alcohol being included in the disease name, and the second is related to attitudes towards being overweight and obesity, which characterize most people with NAFLD/NASH. Indeed, weight stigma, which particularly affects people with obesity in social and medical settings,[12] can increase psychosocial stress and aggravate metabolic and sleep disorders leading to a vicious circle of weight gain[5–7] and consequent progression of NAFLD. It also impairs self-regulation, self-esteem and body image and weakens stress coping mechanisms; the confluence of these factors impedes behavioural change and engagement in weight loss programs.[4,13] Furthermore, weight stigma can negatively affect the mental health of people with obesity, who are particularly vulnerable to depression.[3,14] Stigma and its associated psychosocial stress have also been shown to negatively affect weight loss maintenance.[3]

Social media platforms, such as Twitter, can contribute to further driving weight stigma and discrimination. As such, the large volumes of unsolicited and spontaneous personal opinions on social media platforms can be useful for researchers to explore perceived stigma and how it is developed. Access to such expanded information has the potential to uncover a wide spectrum of stigma experiences, wherever and whenever they occur or are reported. For instance, one study examining social media platform (Twitter, Facebook, YouTube, Flickr and forums) interactions about weight found that Twitter was the most common channel (91% of the dialogue) and that negative weight stigmatization was the most prevalent theme.[15]

To our knowledge, NAFLD/NASH on Twitter have only partially been studied[16] and, therefore, the primary aim of this study is to characterize how stigma and discrimination concerning NAFLD, NASH and obesity manifest on the social media platform Twitter, via a custom data processing pipeline applying Natural Language Processing (NLP) and advanced visualized analytics to support a descriptive statistical analysis.