An exploratory examination of internalized weight stigma in a sample living with food insecurity

The need for more inclusive measurement to advance equity in eating disorders prevention

Eating disorder (ED) research and practice have been shaped by prevailing stereotypes about who EDs are most likely to affect. Subsequently, the field has prioritized the needs and concerns of affluent, cisgender, heterosexual, white girls and women to the exclusion of others, especially people marginalized based on their race, ethnicity, sexual orientation, and/or gender identity. However, EDs exist across diverse groups and actually occur with elevated prevalence in several marginalized groups. Growing research points to differences in the drivers of EDs in such groups (e.g. desire to attain the curvy rather than thin ideal; dietary restraint due to food insecurity rather than weight/shape concerns), yet tools typically used for screening and intervention evaluation do not capture eating pathology driven by such factors. In this commentary, we describe gaps in existing ED assessment tools and argue these gaps likely underestimate EDs among marginalized groups, bias who is invited, participates in, and benefits from ED prevention programs, and obscure potential group differences in the efficacy of such programs. We also discuss the potential of these ramifications to exacerbate inequities in EDs. Finally, we outline recommendations to overcome existing gaps in measurement and, consequently, advance equity in the realm of ED prevention.

A systematic review of weight stigma and disordered eating cognitions and behaviors

Weight stigma is persistent across contexts and is associated with disordered eating cognitions and behaviors. This systematic review aimed to examine the existing literature that has explored the relationship between weight stigma and disordered eating cognitions and behaviors. We specifically examined three dimensions of weight stigma - experienced, anticipated, and internalized - and adopted an inclusive conceptualization of outcomes related to disordered eating (including constructs such as binge eating, body dissatisfaction, and other cognitions and behaviors such as dietary restraint, unhealthy weight control behaviors, and drive for thinness). We searched PubMed, Embase, CINAHL, Web of Science, Sociological Abstracts, and PsycINFO for English-language, peer-reviewed articles and dissertations with quantitative methodology published through October 2023. The search resulted in 242 articles meeting inclusion criteria. A narrative review found a consistent relationship between greater weight stigma and more disordered eating cognitions and behaviors. Methodological and theoretical limitations are discussed, as are critical avenues for future research and potential clinical implications stemming from this body of research. Given the widespread nature and impact of weight stigma on disordered eating, it is imperative that we intervene to address weight stigma at all levels, from the structural to the intrapersonal.

Preliminary associations of body weight, weight bias, and dietary restriction with eating disorder diagnosis in women experiencing food insecurity

Understanding the co-occurrence of food insecurity and eating disorders is a pressing concern. Several factors have been hypothesized to increase risk for eating disorders in women with food insecurity including dietary restriction, body weight, and weight-related bias, but few studies have tested these factors simultaneously to determine which are associated most strongly with eating disorder status. We tested cross-sectional associations of dietary restriction, current body mass index (BMI), weight suppression (i.e. the difference between current weight and highest weight), and weight bias with eating disorder diagnosis in a sample of 99 self-identified women with current food insecurity (54% White; mean [SD] age = 40.26 [14.33] years). Participants completed two virtual study visits consisting of electronic questionnaires and interviews. A binary logistic regression model was conducted to test relations between the hypothesized correlates and eating disorder diagnostic status in the past 12 months, controlling for age, food insecurity severity, and body dissatisfaction. Higher levels of weight suppression and weight bias, but not current BMI, were significantly associated with the presence of an eating disorder. Contrary to our hypothesis, greater dietary restriction was associated with lower likelihood of eating disorder diagnosis. Results suggest high levels of weight bias and weight suppression characterize women with food insecurity who meet criteria for an eating disorder. Women who experience food insecurity and have lost a relatively great deal of weight and/or hold biases about high weight should be screened for eating pathology in clinical settings.

Internalized Weight Stigma and Weight Discrimination: Associations with Quality of Life and Psychosocial Impairment in a Sample Living with Food Insecurity

Research suggests that experiencing weight discrimination is associated with a lower quality of life and poor psychological and physical health. However, much of the existing weight discrimination literature has neglected under-represented groups. Little is known about how the experience of weight discrimination affects quality of life and eating/weight-related psychosocial impairment in those living with food insecurity. The present study investigated the associations of weight discrimination and eating/weight-related psychosocial impairment and quality of life. We examined internalized weight stigma and several psychological indicators as potential mediators. Participants (N = 1085) who were recruited from a local food bank completed a questionnaire assessing food insecurity, weight discrimination, internalized weight stigma, eating disorder pathology, anxiety, depression, eating/weight-related psychosocial impairment, and quality of life. Overall, almost one in four participants reported experiencing weight discrimination. Our serial mediation models indicated that increased experiences of weight discrimination were associated with greater internalized weight stigma and psychopathology, which were in turn associated with lower quality of life and greater eating/weight-related psychosocial impairment. Thus, experiencing weight discrimination may negatively impact quality of life and eating/weight-related psychosocial impairment through its effect on mental health. It is imperative to address the negative effects of the widespread discrimination of people based on their weight.

Associations between household income and disordered eating differ across sex and racial identity in a population-based sample of adults

BACKGROUND

Most research on socioeconomic status (SES) and eating disorders (EDs) has focused on young White women. Consequently, little is known regarding how SES may relate to EDs/disordered eating in older adults, men, or people with different racial identities. We examined whether associations between SES and EDs/disordered eating differed across age, sex, and racial identity in a large, population-based sample spanning early-to-later adulthood.

METHODS

Analyses included 2797 women and 2781 men ages 18-65 (Mage  = 37.41, SD = 7.38) from the population-based Michigan State University Twin Registry. We first examined associations between SES and dimensional ED symptoms, binge eating (BE), and self-reported ED diagnoses across age and sex in the full sample. We then examined the impact of racial identity on associations by conducting within- and between-group analyses among Black and White participants.

RESULTS

In the full sample, lower SES was associated with significantly greater odds of BE and lifetime EDs in men, but not women, across adulthood. The association between lower SES and greater BE risk was stronger for Black men than for White men, though significant in both groups. Conversely, Black women showed a positive association between SES and dimensional ED symptoms that significantly differed from effects for Black men and White women.

CONCLUSIONS

Associations between socioeconomic disadvantage and EDs/disordered eating may be particularly robust for men in adulthood, especially men with a marginalized racial identity. Oppositely, Black women may encounter social pressures and minority stress in higher SES environments that could contribute to somewhat heightened ED risk.

PUBLIC SIGNIFICANCE

Little is known regarding how associations between socioeconomic status (SES) and eating disorders (EDs) may differ across age/sex or racial identity. We found lower SES was associated with greater odds of a lifetime ED or binge eating in men only, with a particularly strong association between lower SES and binge eating for Black men. Results highlight the importance of examining how SES-ED associations may differ across other aspects of identity.

"If I start panicking over having enough, then I start eating too much": Understanding the eating behaviors of SNAP recipients in larger bodies during COVID-19

BACKGROUND/OBJECTIVE

Living in a food-insecure household may increase the risk for disordered eating. Though the Supplemental Nutrition Assistance Program (SNAP) was designed to reduce food insecurity, it may increase risk for disordered eating with the frequency in which benefits are distributed. Limited research has explored the lived experiences of managing eating behaviors while on SNAP, particularly among SNAP participants in larger bodies, and during COVID-19. Thus, the purpose of this study is to examine the experiences with eating behaviors among adults with a BMI ≥ 25 kg/m², and who received SNAP benefits during the COVID-19 pandemic.

METHODS

Eligible adults were recruited to participate in a semi-structured interview. Interviews were transcribed verbatim and analyzed using thematic analysis and content analysis.

RESULTS

Participants (N = 16), had a mean (±SD) age of 43.4 ± 10.9 years, and overwhelmingly identified as female (86 %). One-third of the participants were Black. We identified 4 main themes: (1) not having enough money/benefits to cover needs; (2) navigating loss of control and emotional eating; (3) making sure the kids are alright; and (4) still feeling the pressure to manage weight.

CONCLUSION

Managing eating behaviors while also navigating SNAP benefits is complex and may exacerbate risk of disordered eating.

Do the SCOFF items function differently by food-security status in U.S. college students?: Statistically, but not practically, significant differences

Despite food insecurity (FI) being associated with eating disorders (EDs), little research has examined if ED screening measures perform differently in individuals with FI. This study tested whether items on the SCOFF performed differently as a function of FI. As many people with FI hold multiple marginalized identities, this study also tested if the SCOFF performs differently as a function of food-security status in individuals with different gender identities and different perceived weight statuses. Data were from the 2020/2021 Healthy Minds Study (N = 122,269). Past-year FI was established using the two-item Hunger Vital Sign. Differential item functioning (DIF) assessed whether SCOFF items performed differently (i.e., had different probabilities of endorsement) in groups of individuals with FI versus those without. Both uniform DIF (constant between-group difference in item-endorsement probability across ED pathology) and non-uniform DIF (variable between-group difference in item-endorsement probability across ED pathology) were examined. Several SCOFF items demonstrated both statistically significant uniform and non-uniform DIF (ps < .001), but no instances of DIF reached practical significance (as indicated by effect sizes pseudo ΔR2 ≥ 0.035; all pseudo ΔR2's ≤ 0.006). When stratifying by gender identity and weight status, although most items demonstrated statistically significant DIF, only the SCOFF item measuring body-size perception showed practically significant non-uniform DIF for perceived weight status. Findings suggest the SCOFF is an appropriate screening measure for ED pathology among college students with FI and provide preliminary support for using the SCOFF in individuals with FI and certain marginalized identities.

Food insecurity, weight-based discrimination, weight self-stigma, and mental health in post-bariatric surgery patients

The United States Department of Agriculture defines food insecurity (FI) as reduced quality and variety of diet or overall reduced food intake. To date, limited research has investigated the relationship between FI, weight stigma, and bariatric surgery. The existing literature suggests that FI in bariatric surgery patients is significantly associated with being a person of color, depression, receiving Medicare or Medicaid, and higher eating disorder (ED) pathology. Research also suggests that weight stigma in bariatric surgery patients is associated with worsened weight loss outcomes. No research to our knowledge has investigated FI, internalized weight stigma, weight-based discrimination, and history of bariatric surgery in one sample. Bariatric surgery patients in this study (N = 266) reported elevated rates of FI relative to the general population, via an online questionnaire. Those with FI also reported higher rates of depression, anxiety, ED pathology, internalized weight stigma, and experiences of weight-based discrimination compared to those who were food secure. Given these findings, bariatric surgical centers should evaluate all potential patients for FI before surgery and, at the bare minimum, provide additional support before and post-surgery. The ethics of conducting bariatric surgery in those with FI who lack significant medical comorbidity also must be considered.

Disadvantage and disordered eating in boys: Examining phenotypic and genotype × environment associations across development

Socioeconomic disadvantage may be a significant risk factor for disordered eating, particularly for individuals with underlying genetic risk. However, little to nothing is known about the impact of disadvantage on disordered eating in boys during the critical developmental risk period. Crucially, risk models developed for girls may not necessarily apply to boys, as boys show different developmental patterns of disordered eating risk (i.e., earlier activation of genetic influences during adrenarche, an early stage of puberty). This is the first study to examine phenotypic and Genotype × Environment (G × E) effects of disadvantage in boys. Analyses examined 3,484 male twins ages 8-17 (Mage = 12.27, SD = 2.96) from the Michigan State University Twin Registry. Disordered eating (e.g., body dissatisfaction, binge eating) was measured using the parent-report Michigan Twins Project Eating Disorder Survey. Neighborhood disadvantage was measured using a census-tract level Area Deprivation Index, and family socioeconomic status was determined from parental income and education. Adrenarche status was determined using multiple indicators, including age and Pubertal Development Scale scores. G × E models suggested that genetic influences on disordered eating were activated earlier for boys experiencing familial or neighborhood disadvantage, with substantial genetic influences in early adrenarche, when genetic influences were low in more advantaged boys. Phenotypically, both neighborhood and familial disadvantage were associated with greater disordered eating for boys in late adrenarche, which could indicate a lasting impact of earlier activation of genetic influences on later risk. Results highlight disadvantage as a novel risk factor for disordered eating in boys, particularly those with genetic vulnerabilities. (PsycInfo Database Record (c) 2023 APA, all rights reserved).