The psychological and physiological effects of interacting with an anti-fat peer

How conceptualizing obesity as a disease affects beliefs about weight, and associated weight stigma and clinical decision-making in health care

OBJECTIVES

This study empirically investigated how conceptualizing obesity as a disease (i.e., pathologizing obesity) affects beliefs about weight, and weight stigma and discrimination among health professionals.

DESIGN

An experiment that manipulated the pathologization of obesity was completed by a multi-nation sample of health professionals from Australia, UK, and USA (N = 365).

METHODS

Participants were randomly assigned to one of two conditions where they were asked to conceptualize obesity as a disease or not a disease; then presented with a hypothetical medical profile of a patient with obesity who was seeking care for migraines. We measured biogenetic causal beliefs about obesity, endorsement of weight as a heuristic for health, negative obesity stereotypes, and treatment decisions.

RESULTS

Participants in the disease (vs. non-disease) condition endorsed biogenetic causal beliefs more strongly and made more migraine-related treatment recommendations. No effect of the manipulation was found for the remaining outcomes. Biogenetic causal beliefs about obesity were associated with less weight stigma. Endorsing weight as a heuristic for health was associated with greater weight stigma and differential treatment recommendations focused more on the patient's weight and less on their migraines.

CONCLUSIONS

Pathologizing obesity may reinforce biogenetic explanations for obesity. Evidence demonstrates complex associations between weight-related beliefs and weight stigma and discrimination. Biogenetic causal beliefs were associated with less weight stigma, while endorsing weight as a heuristic for health was associated with greater weight stigma and differential treatment. Further research is needed to inform policies that can promote health without perpetuating weight-based rejection in health care.

Identity and weight-related beliefs among Black, Black/White biracial, East Asian, Hispanic/Latino, Native American, South Asian, and White U.S. Americans

In the current study we move away from bias-focused, White-centric research to examine relationships between gender, race/ethnicity, and weight-related attitudes, identity, and beliefs among Black, Black/White Biracial, East Asian, Hispanic/Latino, Native American, South Asian, and White U.S. Americans who self-identify as higher weight. The results showed that: (1) women identify as fat more than men do, (2) fat identity, operationalized as feelings of similarity to fat people (self-stereotyping) and importance of weight to one's sense of self (identity centrality) are relatively similar across races and ethnicities, and (3) fat identity and weight-related beliefs are related to positivity toward fat people across the racial/ethnic groups sampled in this study.

Challenging oppression: A social identity model of stigma resistance in higher-weight individuals

Many higher-weight individuals have internalised societal weight stigma, devaluing themselves because of their weight. Rejecting and challenging societal devaluation is generally associated with superior outcomes compared with stigma internalisation or inaction; however, stigma resistance has not been studied in higher-weight individuals, despite ubiquitous weight stigma in daily life. Applying a social identity framework, we utilised decision tree analysis to explore predictors of responses to weight stigma in 931 self-classified higher-weight individuals. While ingroup identification with the group 'Fat' was the major predictor of stigma resistance (versus internalisation), perceived illegitimacy of societal weight stigma defined a subgroup of resisters even in the absence of group identity. Interventions focusing on the illegitimacy of unequal social status and treatment may be effective at reducing internalisation and fostering resistance in a population with characteristically low ingroup identity.

Pathways from sociocultural and objectification constructs to body satisfaction among women: The U.S. Body Project I

Objectification theory proposes that widespread sexualization causes women to engage in surveillance of their appearance. We integrated this concept into a model with constructs from the tripartite influence model, which proposes that body dissatisfaction is a result of internalizing cultural notions of thin ideal beauty that stem from family, peer, and media appearance-related pressures. We tested this model with an online sample of 6327 adult women. Specifically, we tested whether these pressures predicted increased thin-ideal and muscular-ideal internalization, leading to greater body surveillance, and in turn lower appearance evaluation and body image quality of life. Structural equation modeling supported many aspects of the model. Family, peer, and media pressures related to higher thin-ideal internalization, which related to higher body surveillance and lower appearance evaluation. Peer and media pressures related to higher muscular-ideal internalization, which related to lower appearance evaluation. However, muscular-ideal internalization was not related to body image quality of life. An indirect relationship emerged between thin-ideal internalization and body image outcomes via body surveillance. Body mass index (BMI) moderated several of these model paths. Findings highlight the value of this integrated sociocultural model, and of BMI as an important moderating factor when examining objectification and tripartite influence models.

Pathways from sociocultural and objectification constructs to body satisfaction among men: The U.S. Body Project I

According to the tripartite influence model, body dissatisfaction is shaped by internalizing cultural appearance ideals stemming from appearance-related family, peer, and media pressures. This model was developed for women, but emerging evidence points to its relevance for men's body image. This study advanced this budding research by (a) integrating muscular-ideal internalization alongside lean-ideal internalization and body surveillance into the model, (b) examining two positive dimensions of body image as outcomes (body image quality of life and appearance evaluation), and (c) testing this model in national online sample of 5293 men. Structural equation modeling supported the model. Family, peer, and media pressures related to higher lean-ideal internalization, which related to higher body surveillance and poorer body image outcomes. Peer and media pressures related to higher muscular-ideal internalization, which related to higher body surveillance but more adaptive body image outcomes. We further examined whether model variables and paths differed based on men's body mass index (BMI). Men with higher BMIs evidenced a stronger path between body surveillance and body image outcomes. These findings highlight the usefulness of sociocultural models for understanding men's body image experiences.

Evaluation of the psychometric properties of self-reported weight stigma measures: A systematic literature review

OBJECTIVE

Conceptualisation and measurement of weight stigma varies across available studies assessing those affected. This paper aims to systematically review the psychometric properties of available self-reported measures of weight stigma.

METHOD

Studies exploring the development and/or validation of weight stigma measures were identified through systematically searching Medline, CINAHL, PsycINFO, Embase, Web of Science, and Scopus databases. The Consensus-based Standards of Health Measurement Instruments (COSMIN) checklist was used to assess the psychometric properties of measures.

RESULTS

Thirty-six articles, reporting 18 different weight stigma measures, were included. For most included measures, measure development and content validity have not been assessed/reported. Structural validity, internal consistency, and hypothesis testing were the most commonly assessed/reported psychometric properties. High-quality ratings were given only for these properties. Most measures were rated as "indeterminate" and received an overall quality rating of "Very Low" as results were based on limited evidence.

CONCLUSIONS

Psychometric properties for published weight stigma measures have rarely been assessed/reported. The observed poor methodological quality for measure development, and limited content validity evidence, negatively impact the quality of evidence for the measures. There is a need for studies assessing the psychometric properties of existing weight stigma measures using COSMIN guidelines, and for a well-designed weight stigma measure informed by both theory and research.

Weight stigma and health – Repercussions on the health of adolescents and adults: integrative review of the literature

ABSTRACT Objective To conduct an integrative review in order to understand the repercussions of the social stigma of overweight on the health of adults and adolescents. Methods The international protocol for systematic review and meta-analysis studies PRISMA was adopted to guide the writing of this review. The databases used were PubMed, Psycinfo, SciELO, Medline, Lilacs and Pepsic, considering studies published in the period from 2000 to 2020. Sixty-seven (67) articles were analyzed, and 4 categories emerged: repercussions on physical well-being; repercussions on social well-being; repercussions on mental well-being; and mixed category (physical and psychological impact). Results In the vast majority of studies analyzed, weight stigma had a negative impact on the different spheres that make up the health construct, that is, the physical, social and mental spheres. Conclusions The consequences of weight stigma are a source of intense suffering, with an impact that reduces the quality of life of individuals who experience stigmatization, involving physical, emotional and social aspects.

Weight stigma and health behaviors: evidence from the Eating in America Study

BACKGROUND

Weight stigma is pervasive across the U.S. and is associated with poor health outcomes including all-cause mortality. One potential reason that weight stigma may be detrimental to health is that it begets poorer health behaviors. Therefore, the present study tested for associations between weight stigma and four health behaviors (i.e., eating behavior, alcohol use, sleep disturbance, and physical activity), while controlling for BMI and other potential confounds.

SUBJECTS/METHODS

Participants (N = 2022) in the U.S. were recruited for the Eating in America Study using a Qualtrics panel between December 2019 and January 2020 and were census-matched according to national quotas for age, gender, income, race/ethnicity, and census region. Participants completed questionnaires about weight stigma, health behaviors, demographics, and anthropometric measurements. The current study employed a two-stage investigation: exploratory analyses were first performed on a random sample of the dataset (n = 438), then the remaining unexamined data were used to conduct confirmatory analyses that were preregistered on the Open Science Framework.

RESULTS

Controlling for BMI, weight stigma was significantly associated with greater disordered eating (b = 0.34, 95% CI [0.31, 0.38], p < 0.001), comfort eating (b = 0.32, 95% CI [0.25, 0.39], p < 0.001), sleep disturbance (b = 0.27, 95% CI [0.20, 0.33], p < 0.001), and alcohol use (b = 0.30, 95% CI [0.11, 0.49], p = 0.002), but not lower physical activity (b = -0.04, 95% CI [-0.13, 0.05], p = 0.402) for individuals across the weight spectrum. BMI and perceived weight status significantly moderated the effects of weight stigma on disordered eating and alcohol use. No gender differences were found. These confirmatory analyses partially replicated the exploratory stage 1 findings.

CONCLUSIONS

This study provides preliminary evidence that weight stigma is linked to several poor health behaviors, which may impact physical health.

Association Between Body Mass Index and Female Sexual Dysfunction: A Cross-sectional Study from the Data Registry on Experiences of Aging, Menopause, and Sexuality

BACKGROUND

Obesity and female sexual dysfunction (FSD) are prevalent conditions, and both are associated with significant adverse effects on health and well-being.

AIM

To investigate the association between body mass index and FSD, as well as potential moderators.

METHODS

This cross-sectional study was performed by analyzing medical records of 6,688 women seeking consultation for menopause-related or sexual health-related concerns at women's health clinics at Mayo Clinic Rochester, MN, and Scottsdale, AZ, between May 1, 2015, and September 15, 2019.

OUTCOMES

Female sexual function was assessed by the Female Sexual Function Index, and sexual distress was assessed by the Female Sexual Distress Scale-Revised.

RESULTS

Being overweight or obese was associated with a lack of sexual activity. Among sexually active women, those who were overweight or obese had lower Female Sexual Function Index total scores and sexual function domain scores (indicating worse sexual function), including sexual arousal, lubrication, satisfaction, orgasm, and pain, and higher levels of sexual distress than those with normal weight. However, on multivariable analysis, these associations were found to be mediated by other factors, including age, level of education, reproductive stage, medication use, and mood disturbances, which are known to impact body weight and sexual function in women.

CLINICAL IMPLICATIONS

Overweight and obesity were associated with sexual inactivity and greater odds of having FSD, which should prompt proactive assessment of sexual function.

STRENGTHS AND LIMITATIONS

The strengths of this study include the large cohort size and assessment of sexual problems in addition to sexual distress, a key component of the definition of sexual dysfunction. This study also took into account multiple potential moderating factors. Limitations include the cross-sectional design, which precludes determination of causality as well as lack of diversity in the cohort, potentially limiting generalizability of results. In addition, sexual function was not assessed in women reporting no recent sexual activity, which may confound results.

CONCLUSION

Overweight/obesity and FSD are highly prevalent conditions, which appear to be indirectly associated. These results highlight the need to identify and address FSD in all overweight and obese women, with particular attention to potential contributing factors. Faubion SS, Fairbanks F, Kuhle CL, et al. Association Between Body Mass Index and Female Sexual Dysfunction: A Cross-sectional Study from the Data Registry on Experiences of Aging, Menopause, and Sexuality. J Sex Med 2020;17:1971-1980.

The role of psychological attribution in responses to weight stigma

Objective

Weight discrimination is associated with numerous negative health consequences. Little is known about early‐stage psychological mechanisms that explain variability in responses to weight discrimination among people with obesity. This study tested the hypothesis that attributing negative social evaluation to one's weight would be associated with stigma‐related stress responses (eg, reduced cognitive functioning and self‐esteem, increased negative affect and cortisol), especially among people who had experienced frequent weight discrimination in the past.

Methods

Adults (N = 109) with obesity were randomly assigned to receive a mildly positive (control) versus negative social evaluation. The extent to which participants attributed the negative evaluation to their physical appearance was assessed, along with negative affect, social and appearance self‐esteem, cognitive functioning and salivary cortisol.

Results

Participants who had experienced frequent weight discrimination in the past were more likely to attribute the negative evaluation to their appearance. Participants who attributed the negative evaluation to their appearance in turn experienced elevated negative affect, lower appearance self‐esteem and worse cognitive functioning.

Conclusions

This study is among the first to identify attribution as an early‐stage process underlying responses to weight stigma. Attribution may be a key psychological factor conferring risk for or protection from the negative effects of weight stigma.

A bifactor analysis of the Weight Bias Internalization Scale: What are we really measuring?

Internalized weight stigma (IWS) has been linked with disordered eating behavior, both directly, and as a mediator of the relationship between experienced weight stigma and maladaptive coping. However, the construct of IWS is highly correlated with the related constructs of body image and global self-esteem, and the three constructs may better be represented by underlying trait self-judgment. This overlap is not generally accounted for in existing studies. The present study investigated the shared variance between self-esteem, body image, and IWS in an international sample of higher-weight individuals. Bifactor analysis confirmed that the intermediary role of IWS in the relationship between experienced stigma and self-reported eating behavior was largely accounted for by aspects of body image and global self-esteem. Greater conceptual clarity in the study of IWS is needed to understand the mechanisms via which societal weight stigma impacts on individuals' self-directed judgments and downstream health-related behaviors.

Weight discrimination, anticipated weight stigma, and disordered eating

Weight discrimination is a well-established risk factor for disordered eating cognitions and behaviors. However, little is known about what may account for this association. Recent research suggests that anticipated weight stigma may explain the relationship between weight discrimination and non-eating disorder related health outcomes; the present study seeks to replicate this premise and extend it to the disordered eating realm. In a non-clinical sample of adults in the United States (N = 297) we test the hypothesis that weight discrimination has an indirect association with eating disorder symptomatology through anticipated stigma. At a single timepoint, participants recruited from the online data collection platform SocialSci completed self-report, online surveys of weight discrimination in day-to-day life, anticipated weight stigma, eating disorder symptoms, and demographic information. As hypothesized, weight discrimination was indirectly associated with greater disordered eating symptoms via its association with anticipated weight stigma. This pattern of results held when controlling for gender, body mass index, and self-perceived weight status. These findings suggest that anticipated stigma is relevant in the association between weight discrimination and greater disordered eating. This premise deserves additional attention using methodological approaches that can facilitate stronger causal claims. We discuss the potential for this line of research to inform clinical interventions.

The Countervailing Effects of Weight Stigma on Weight-Loss Motivation and Perceived Capacity for Weight Control

We hypothesized that exposure to weight stigma simultaneously increases motivation to lose or avoid gaining weight to avoid future stigma and decreases perceived capacity to do so, by heightening concerns about experiencing stigma and negative affect. Study 1 showed that more frequently experiencing weight-based discrimination was associated with greater concerns about being a victim of weight stigma, which predicted increased motivation to lose weight but decreased perceived capacity for weight control. Study 2 showed that participants randomly assigned to view a weight-stigmatizing (vs. control) message showed increased concerns about being a target of weight stigma, which indirectly increased motivation to lose weight and decreased state self-control. These, in turn, predicted increased willingness to engage in unhealthy weight-loss behaviors and decreased perceived capacity for weight control, respectively. Study 3 showed that increased motivation to avoid stigma and increased negative affect mediate these effects of exposure to weight stigma.

Weight-related stigma mediates the relationship between weight status and bodily pain: A conceptual model and call for further research

Women are disproportionately impacted by pain compared to men, highlighting the need to better understand factors that contribute to this gender disparity. Previous findings suggest weight-related stigma may be associated with pain among women attempting to lose weight. The goal of this study is to determine if experienced and/or internalized weight bias mediate the relationship between body mass index (BMI) and pain-related impairment in a large, community-based sample of women across the weight spectrum (N = 309; M_Age = 56.5, SD = 14.5; M_BMI = 28.5, SD = 7.1), and to evaluate whether this relationship differs for women with a pain condition. Analyses were performed using the Conditional-PROCESS Macro to examine the relationships between BMI, pain-related impairment, internalized and experienced weight-stigma, and the potentially moderating effect of pain-related conditions on these relationships. After adjusting for covariates, both experienced stigma and internalized weight stigma statistically mediated the BMI and pain-related impairment relationship; however, in the tests of moderated mediation, the indirect effect of internalized weight bias only held true for those without pain conditions. These findings offer a preliminary conceptual model and highlight the importance of pain research to include weight-related stigma.

The relationship between weight stigma, weight bias internalization, and physical health in military personnel with or at high-risk of overweight/obesity

Perceived weight stigma is associated with adverse health indices, such as elevated cortisol, lipid/glucose dysregulation, and poorer self-rated health. This relationship may be particularly relevant for military personnel, given the cultural emphasis on fitness and weight/shape. Therefore, we investigated the relationship between weight stigma and physical health in 117 active duty personnel (66.7% male; 56.4% non-Hispanic White; age: 30.8 ± 7.4 years; BMI: 29.5 ± 2.5 kg/m²). Participants reported weight stigma (general and military-specific), weight bias internalization, and the presence (≥1; n = 55) or absence (n = 62) of medical conditions. Logistic regressions were conducted examining the ability of weight stigma (general or military-specific) and weight bias internalization to predict the presence or absence of medical conditions. General weight stigma was not significantly associated with the presence of a medical condition (p > .05). However, individuals with military-specific weight stigma scores twice that of their peers were over three times more likely (p =  .04) to report a medical condition. Weight bias internalization was not significant in any model (ps > .20). Longitudinal studies should prospectively examine the relationship between weight stigma in the military setting and health among service members.