The economic and social costs of body dissatisfaction and appearance-based discrimination in the United States

This study estimated the social and economic costs of body dissatisfaction and appearance-based discrimination (specifically, weight and skin-shade discrimination) in the United States (USA) in the 2019 calendar year. We used a prevalence-based approach and a cost-of-illness method to estimate the annual cost of harmful appearance ideals for cases of body dissatisfaction and discrimination based on weight and skin shade. Impacts on conditions/illnesses such as eating disorders that are attributable to body dissatisfaction, weight discrimination and skin-shade discrimination were identified through a quasi-systematic literature review, which captured financial, economic, and non-financial costs. For each impact attributable to body dissatisfaction or appearance-based discrimination, annual health system and productivity costs (or labor market costs) were primarily estimated by using a population attributable fraction methodology. Only direct costs that resulted from body dissatisfaction and appearance-based discrimination were included (for example, costs associated with conditions such as depression attributable to body dissatisfaction or appearance-based discrimination). In contrast, indirect costs (e.g. costs associated with a health condition developed following skin bleaching, which was undertaken as a result of body dissatisfaction) were not included. In 2019 body dissatisfaction incurred $84 billion in financial and economic costs and $221 billion through reduced well-being. Financial costs of weight discrimination and skin-shade discrimination were estimated to be $200 billion and $63 billion, respectively, and reduced well-being was estimated to be $206.7 billion due to weight discrimination and $8.4 billion due to skin-shade discrimination. Sensitivity testing revealed the costs likely range between $226 billion and $507 billion for body dissatisfaction, between $175 billion and $537 billion for skin-shade discrimination, and between $126 billion and $265 billion for weight discrimination. This study demonstrates that the prevalence and economic costs of body dissatisfaction and weight and skin-shade discrimination are substantial, which underscores the urgency of identifying policy actions designed to promote prevention.

Weight Bias Among Certified Nurse-Midwives and Certified Midwives: Findings From a National Sample

INTRODUCTION

Weight bias toward individuals with higher body weights permeates health care settings in the United States and has been associated with poor weight-related communication and quality of care as well as adverse health outcomes. However, there has been limited quantitative investigation into weight bias among perinatal care providers. Certified nurse-midwives (CNMs)/certified midwives (CMs) attend approximately 11% of all births in the United States. The aims of this study were to measure the direction and extent of weight bias among CNMs/CMs and compare their levels of weight bias to the US public and other health professionals.

METHODS

Through direct postcard distribution, social media accounts, professional networks, and email listservs, American Midwifery Certification Board (AMCB)-certified midwives were solicited to complete an online survey of their implicit weight bias using the Implicit Association Test and their explicit weight bias using the Antifat Attitudes Questionnaire, Fat Phobia Scale, and Preference for Thin People measure.

RESULTS

A total of 2257 midwives participated in the survey, yielding a completion rate of 17.7%. Participants were mostly White and female, with a median age of 46 years and 11 years since AMCB certification. More than 70% of midwives have some level of implicit weight bias, although to a lesser extent compared with previously published findings among the US public (P < .01) and other health professionals (P < .01). In a subsample comparison of female midwives to female physicians, implicit weight bias levels were similar (P > .05). Midwives also express explicit weight bias, but at lower levels than the US public and other health professionals (P < .05).

DISCUSSION

This study provides the first quantitative research documenting weight bias among a national US sample of perinatal care providers. Findings can inform educational efforts to mitigate weight bias in the perinatal care setting and decrease harm.

Parent-Adolescent Weight Communication: Parental Psychosocial Correlates Among a Diverse National Sample

Parental communication about body weight with their children is common across diverse families. The current study investigates how parents' feelings about their own bodies, beliefs about body weight, history of weight stigma, and weight-related characteristics contribute to the degree to which they talk about weight - both negatively and positively - with their adolescent children. The study sample was comprised of U.S. parents (N = 1936) from diverse racial/ethnic backgrounds with children aged 10-17 years old. Parents completed an online survey with measures assessing their frequency of engaging in negative and positive weight communication with their children, along with several relevant psychosocial factors (i.e. body satisfaction, experienced weight stigma, associative stigma, body appreciation, beliefs about weight controllability, weight bias internalization). Study findings paint a complex picture, including some psychosocial factors (e.g. weight bias internalization) that are related to both more frequent negative and positive weight communication. Notably, higher levels of associative stigma were related to more frequent negative parental weight comments, and less frequent positive weight socialization. Findings can inform healthcare professionals in raising parents' awareness about how their personal beliefs and feelings about their own weight and their child's weight can contribute to how they engage in communication about weight with their children.

Bias-based bullying, self-esteem, queer identity pride, and disordered eating behaviors among sexually and gender diverse adolescents

OBJECTIVE

Limited research incorporates an intersectional approach when evaluating disordered eating behaviors among those holding minoritized social positions, such as lesbian, gay, bisexual, queer, questioning, and/or transgender/gender diverse (LGBTQ) adolescents. The current study assessed stigma experiences from peers at school, self-esteem, LGBTQ pride, and overlapping social positions as they relate to disordered eating behaviors among LGBTQ adolescents.

METHOD

Participants included 11,083 adolescents (Mage  = 15.6, SD = 1.3; 34.8% transgender/gender diverse) from a large national survey study of LGBTQ adolescents from 2017. Exhaustive Chi-square Automatic Interaction Detection analysis was used to identify bias-based bullying experiences (i.e., weight-based, identity-based), self-esteem, LGBTQ pride, and overlapping social positions (i.e., gender identity, sexual identity, race/ethnicity, body mass index (BMI) percentile) associated with the highest prevalence of unhealthy weight control behaviors, extreme unhealthy weight control behaviors, and past year binge eating.

RESULTS

Adolescents in the 28 identified groups with a high prevalence of disordered eating behavior held at least one structurally marginalized social position (e.g., high BMI), bias-based bullying experience, low self-esteem, or low LGBTQ pride in addition to being LGBTQ. Weight-based bullying was a salient risk-factor for disordered eating across social positions. Among adolescents with the same social positions, levels of self-esteem, LGBTQ pride, but no bias-based bullying experience, prevalence estimates of disordered eating were, on average, 23% lower.

DISCUSSION

LGBTQ adolescents with multiple marginalized social positions and related factors engage in disproportionately high prevalence disordered eating. Findings underscore the importance of addressing intersecting experiences of stigma to reduce disordered eating and promote health equity among adolescents.

PUBLIC SIGNIFICANCE

Multiply marginalized LGBTQ adolescents, most of whom also reported experiencing bias-based bullying from peers at school, reported disproportionately high prevalence disordered eating. In comparison groups of adolescents with no bias-based bullying experience, prevalence of disordered eating was, on average, 24% lower. Findings underscore the importance of addressing intersecting experiences of stigma to reduce disordered eating and promote health equity among adolescents.

An Examination of Parental Weight Stigma and Weight Talk Among Socioeconomically and Racially/Ethnically Diverse Parents

Parental communication about body weight can influence children's emotional well-being and eating behaviors. However, little is known about the role of parental self-stigma concerning weight and social position variables (ie, race/ethnicity, income, and gender) in weight communication. This study examined how parents' self-stigmatization for their own weight (ie, weight bias internalization) and self-stigmatization for their child's weight (ie, affiliate stigma) relates to weight talk frequency with their children, and whether these associations vary across parental race/ethnicity, income, and gender. Parents (n = 408) completed a cross-sectional, online survey about their weight communication and self-stigmatization. Linear regression was used to examine the relationships among these variables, including interactions between the stigma variables and social position variables in predicting weight talk. Higher levels of weight bias internalization and affiliate stigma were strongly associated with increased parental weight talk frequency; parents who endorsed higher levels of internalized bias about their own weight expressed greater affiliate stigma for their child's weight, regardless of demographic characteristics or weight status. Associations between the stigma variables and weight talk outcomes were stronger among fathers and parents of higher income. Findings highlight the importance of considering weight stigma variables in parental weight communication research.

Changing the global obesity narrative to recognize and reduce weight stigma: A position statement from the World Obesity Federation

Weight stigma, defined as pervasive misconceptions and stereotypes associated with higher body weight, is both a social determinant of health and a human rights issue. It is imperative to consider how weight stigma may be impeding health promotion efforts on a global scale. The World Obesity Federation (WOF) convened a global working group of practitioners, researchers, policymakers, youth advocates, and individuals with lived experience of obesity to consider the ways that global obesity narratives may contribute to weight stigma. Specifically, the working group focused on how overall obesity narratives, food and physical activity narratives, and scientific and public-facing language may contribute to weight stigma. The impact of weight stigma across the lifespan was also considered. Taking a global perspective, nine recommendations resulted from this work for global health research and health promotion efforts that can help to reduce harmful obesity narratives, both inside and outside health contexts.

Bringing an end to diabetes stigma and discrimination: an international consensus statement on evidence and recommendations

People with diabetes often encounter stigma (ie, negative social judgments, stereotypes, prejudice), which can adversely affect emotional, mental, and physical health; self-care, access to optimal health care; and social and professional opportunities. To accelerate an end to diabetes stigma and discrimination, an international multidisciplinary expert panel (n=51 members, from 18 countries) conducted rapid reviews and participated in a three-round Delphi survey process. We achieved consensus on 25 statements of evidence and 24 statements of recommendations. The consensus is that diabetes stigma is driven primarily by blame, perceptions of burden or sickness, invisibility, and fear or disgust. On average, four in five adults with diabetes experience diabetes stigma and one in five experience discrimination (ie, unfair and prejudicial treatment) due to diabetes, such as in health care, education, and employment. Diabetes stigma and discrimination are harmful, unacceptable, unethical, and counterproductive. Collective leadership is needed to proactively challenge, and bring an end to, diabetes stigma and discrimination. Consequently, we achieved unanimous consensus on a pledge to end diabetes stigma and discrimination.

Parental Reasons for Engaging in or Avoiding Weight Talk With Children

Parental weight talk with children can have negative consequences; yet, it is not well understood why parents engage in it and if demographic differences exist. Utilizing the extant qualitative literature, we developed two scales to quantitatively examine parental reasons for engaging in and avoiding weight talk. An Internet sample of 408 US parents (64% mothers; 34% White, 33% Black, and 32% Hispanic/Latinx) completed the scales. Parents cited concern for their child's health as a primary reason for weight talk, whereas avoidance stemmed from not wanting their child to be weight-obsessed. White and Hispanic vs. Black parents, and parents with experienced weight stigma, were more likely to cite personal struggles with body weight as reasons to both engage in and avoid weight talk. Fathers vs. mothers were more likely to cite protecting their child from weight-based bullying as a reason for weight talk. Understanding these parental motivations can inform health interventions.

Parental Communication About Body Weight and Adolescent Health: The Role of Positive and Negative Weight-Related Comments

OBJECTIVE

Research has consistently documented adverse effects of parent weight-related comments on adolescent health. However, little empirical attention has focused on isolating the impact of weight-related comments from mothers versus fathers, and the valence of their comments. The present study examined the extent to which positive and negative weight-related comments from mothers and fathers are related to adolescent health and wellbeing, and whether these associations differ according to adolescent sociodemographic characteristics.

METHODS

Data were collected from a diverse sample of 2032 U.S.-based adolescents aged 10-17 years (59% female; 40% White, 25% Black or African American, 23% Latinx). Online questionnaires assessed perceived frequency of negative and positive weight-related comments from mothers and fathers, as well as four indicators of adolescent health and wellbeing: depression, unhealthy weight control behaviors, weight bias internalization (WBI), and body appreciation.

RESULTS

More frequent negative weight-related comments from parents were associated with poorer adolescent health and wellbeing, while positive comments contributed to lower levels of WBI and body appreciation; these associations were documented regardless of whether mothers or fathers were the source of such comments, and considerable consistency was demonstrated across adolescent sociodemographic characteristics.

CONCLUSION

Findings highlight differences in adolescent health based on how parents discuss their body weight (i.e., negatively or positively), and similarity in associations regardless of whether mothers or fathers are the source of weight communication. These findings reiterate the importance of efforts to educate parents on ways to engage in supportive communication about weight-related health with their children.

Diabetes stigma and weight stigma among physicians treating type 2 diabetes: Overlapping patterns of bias

AIMS

Adults with type 2 diabetes (T2D) report experiencing stigma across multiple settings, including stigmatizing interactions with their healthcare providers. However, research examining physician biases toward patients with T2D is scarce. Identifying stigma-related barriers in diabetes care is essential to prevent providers' biases from impairing health care delivery. This study assessed attitudes towards individuals with T2D and obesity among physicians who treat T2D.

METHODS

Physicians specializing in internal medicine or endocrinology (n=205) completed a series of online questionnaires assessing their attitudes towards patients with T2D and obesity, and their attributions of controllability and blame of individuals with T2D and obesity.

RESULTS

While 85% of physicians felt professionally prepared and confident to treat patients with T2D, 1/3 reported being repulsed by patients with T2D and view them as lazy (39%), lacking motivation (44%), and non-compliant with treatment (44%). Many witnessed professionals in their field making negative comments about patients with T2D (44%). Physicians endorsed worse levels of bias towards patients with obesity than T2D, but differences were small.

CONCLUSIONS

Findings highlight the need for stigma reduction interventions for physicians addressing both T2D and obesity. Research assessing the effects of T2D stigma on quality of patient care and health outcomes is needed.

Can Family and Parenting Factors Modify the Impact of Weight Stigma on Disordered Eating in Young People? A Population-Based Longitudinal Study

PURPOSE

Weight stigma is a prevalent problem in adolescents and a risk factor for disordered eating behaviors (DEBs). This study examined whether positive family/parenting factors were protective for DEBs among an ethnically/racially and socioeconomically diverse sample of adolescents with and without weight stigmatizing experiences.

METHODS

In Project Eating and Activity over Time (EAT) 2010-2018, 1,568 adolescents (mean age = 14.4 ± 2.0 years) were surveyed and followed into young adulthood (mean age = 22.2 ± 2.0 years). Modified Poisson regression models examined the relationships between three weight-stigmatizing experiences and four DEBs (e.g., overeating and binge eating) in models adjusted for sociodemographic characteristics and weight status. Interaction terms and stratified models examined whether family/parenting factors were protective for DEBs based on weight stigma status.

RESULTS

Higher family functioning and support for psychological autonomy were cross sectionally protective for DEBs. However, this pattern was primarily observed in adolescents who did not experience weight stigma. For example, among adolescents who did not experience peer weight teasing, high support for psychological autonomy was associated with lower prevalence of overeating (high support: 7.0%, low support: 12.5%, p = .003). Whereas, in participants who experienced family weight teasing, the difference in prevalence of overeating based on support for psychological autonomy was not statistically significant (high support: 17.9%, low support: 22.4%, p = .260).

DISCUSSION

General positive family and parenting factors did not entirely offset the effects of weight-stigmatizing experiences on DEBs, which may reflect the strength of weight stigma as a risk factor for DEBs. Future research is needed to identify effective strategies family members can use to support youth who experience weight stigma.

Weight Stigma and Barriers to Effective Obesity Care

Weight stigma is prevalent with negative consequences for health and well-being. This problem is present in health care; stigmatizing attitudes toward patients with obesity are expressed by medical professionals across diverse specialties and patient care settings. This article summarizes the ways in which weight stigma creates barriers to effective care, including poor patient-provider communication, reduced quality of care, and healthcare avoidance. Priorities for stigma reduction in healthcare are discussed, with a clear need for multifaceted approaches and inclusion of people with obesity whose perspectives can inform strategies to effectively remove bias-related barriers to patient care.

Family-based weight stigma and psychosocial health: A multinational comparison

OBJECTIVE

Family-based weight stigma can be expressed as criticism, judgment, teasing, and mistreatment by family members because of an individual's body weight. The current study compared the prevalence and psychosocial correlates of family-based weight stigma among adult members of a weight-management program living in Australia, Canada, France, Germany, the UK, and the US.

METHODS

Participants (N = 8100 adults who reported having ever experienced weight stigma; 95% female; 94% White) completed an identical online survey in their country's dominant language that assessed their experiences of weight stigma from 16 different family member sources, as well as internalized weight bias, body image, eating behaviors, perceived stress, and self-rated health.

RESULTS

Family-based weight stigma, especially from mothers (49%-62%), spouses/romantic partners (40%-57%), and fathers (35%-48%), was highly prevalent across countries. Weight stigma from one's immediate family members was associated with indices of poorer psychosocial health across the six countries (β coefficients = |0.08-0.13|).

CONCLUSIONS

Findings highlight the need for weight stigma-reduction efforts to help family members distinguish between supportive, encouraging discourse and potentially weight-stigmatizing communication. Future research should examine the prevalence and correlates of family-based weight stigma in more diverse community samples, including among racially/ethnically and gender diverse adults, and in non-Western countries.

Does Diagnostic Certainty Matter?: Pain-Related Stigma in Adolescents with Juvenile Idiopathic Arthritis

OBJECTIVES

Childhood chronic pain conditions are common and vulnerable to stigma. Adolescents with chronic primary pain experience diagnostic uncertainty and describe pain-related stigma experiences across multiple social contexts. Juvenile idiopathic arthritis (JIA) is a childhood autoimmune, inflammatory condition with associated chronic pain, but with well-defined diagnostic criteria. The current study examined pain-related stigma experiences in adolescents with JIA.

METHODS

Four focus groups of 3-7 adolescents with JIA (N = 16), ages 12-17 (Mage = 15.42, SD = 1.82), and parents (N = 13) were conducted to examine experiences of, and reaction to, pain-related stigma. Patients were recruited from an outpatient pediatric rheumatology clinic. Focus group length ranged from 28 to 99 minutes long. Two coders used directed content analysis resulting in 82.17% inter-rater level of agreement.

RESULTS

Adolescents with JIA described pain-related stigma experiences predominantly from school teachers and peers, and less from medical providers (e.g., school nurses), and family members after a diagnosis. The primary categories that emerged were (1) Felt Stigma, (2) Internalized Stigma, (3) Anticipatory Stigma/Concealment, and (4) Contributions to Pain-Related Stigma. A common experience of pain-related stigma was the perception by others that the adolescent was too young to have arthritis.

CONCLUSIONS

In common with adolescents with unexplained chronic pain, our findings indicate that adolescents with JIA experience pain-related stigma in certain social contexts. Diagnostic certainty may contribute to greater support among medical providers and within families. Future research should investigate the impact of pain-related stigma across childhood pain conditions.

Parent-child communication about weight: Priorities for parental education and support

BACKGROUND

Approximately 2/3 of parents talk about body weight with their children, which can include negative comments that have adverse health implications for youth.

OBJECTIVES

To identify ways to improve supportive parent-child communication about weight, we assessed parent and youth perspectives of barriers to weight communication, preferences for educational resources and support, and whether perspectives differ across demographic groups and weight status.

METHODS

In Fall 2021, online surveys were completed by two independent, unrelated samples of parents (N = 1936) and youth (N = 2032). Participants were asked about their perceived barriers to talking about weight, and what kinds of information and support would be most useful to them in fostering supportive communication.

RESULTS

Parent and youth-reported barriers to weight communication included discomfort and lack of knowledge about weight, and views that weight does not need to be discussed. Most parents wanted guidance on how to navigate multiple weight-related topics with their children, including promoting positive body image and healthy behaviours, reducing weight criticism, focusing more on health and addressing weight-based bullying. Youth preferences for how their parents can be more supportive of their weight included avoiding weight-related criticism and pressures, increasing sensitivity and encouragement, and emphasizing healthy behaviours rather than weight. Few differences emerged based on sex and race/ethnicity, although several differences emerged for youth engaged in weight management.

CONCLUSION

Parent and youth perspectives indicate a need for education to help parents engage in supportive conversations about body weight. Findings can inform efforts to reduce barriers and increase supportive weight-related communication in families.

Weight-biased attitudes about pediatric patients with obesity in Dutch healthcare professionals from seven different professions

Little is known about the prevalence of negative weight-biased attitudes among Dutch healthcare professionals (HCPs) when treating children and adolescents with obesity and whether interdisciplinary differences are present. Accordingly, we asked Dutch HCPs that treat pediatric patients with obesity to complete a validated 22-item self-report questionnaire about their weight-biased attitudes. In total, 555 HCPs participated from seven different disciplines: 41 general practitioners (GPs), 40 pediatricians, 132 youth healthcare physicians, 223 youth healthcare nurses, 40 physiotherapists, 40 dieticians, and 39 mental health professionals. HCPs from all disciplines reported to experience negative weight-biased attitudes among themselves. Pediatricians and GPs scored highest on negative weight-biased attitudes, including frustrations in treating children with obesity, and feeling less confident and prepared to treat children with obesity. Dieticians scored the least negative weight-biased attitudes. Participants from all groups perceived weight bias expressed by their colleagues, toward children with obesity. These findings are comparable to results reported by adult HCPs from other countries. Interdisciplinary differences were found and underscore the need for more research on contributing factors that impact explicit weight bias among pediatric HCPs.

"Look beyond the weight and accept me": Adolescent perspectives on parental weight communication

Critical weight communication between parents and their adolescent children is prevalent and harmful. However, research on adolescent perspectives about parental weight communication is limited. The present mixed-methods study aimed to address this gap using inductive thematic analysis of 1743 adolescents' (M_age=14.61 years, SD_age=2.48) preferences regarding parental weight communication in response to an open-ended prompt, and quantitative analyses to examine age, gender, race/ethnicity, and weight-related differences in subthemes. In their responses, adolescents articulated 1) whether and 2) how parental weight communication should-or should not-occur, and 3) what these conversations should entail. We identified 15 subthemes across these categories-the endorsement of which often varied by adolescents' demographic and anthropometric characteristics. For example, some adolescents (especially cisgender girls and transgender/gender diverse adolescents) preferred that their parents talk about weight less often (n = 184), while others (especially multiracial/ethnic or Hispanic/Latinx adolescents) hoped that, if parents were to discuss weight with them, they do so in a manner that was compassionate and respectful (n = 150). Across most subthemes, adolescents described adverse responses (e.g., feeling insecure, embarrassed, or hurt) when parents discussed their weight in non-preferred ways. Collectively, findings can inform interventions to promote more supportive health-focused communication in families.

Patient and Family Perspectives on Terms for Obesity

OBJECTIVES

Parent communication about body weight is a sensitive topic, but limited research has studied youth preferences for words used to talk about their weight with parents. We assessed perspectives of weight-based terminology in 2 racially/ethnically diverse samples of youth and parents.

METHODS

We collected online survey data from 2 panel survey samples between September and December 2021: youth aged 10 to 17 years (n = 2032) and parents of youth aged 10 to 17 years (n = 1936). Participants rated 27 different terms and phrases to describe body weight; parents reported on their usage of this terminology and youth reported their preferences for and emotional responses to terminology. Patterns were examined across sex, race/ethnicity, sexual orientation, and weight status.

RESULTS

Youth reported preferences for words such as "healthy weight" and dislike of terms such as "obese," "fat," and "large," which induced feelings of sadness, shame, and embarrassment. Differences in youth preferences and emotional reactions were present across sex, sexual orientation, race/ethnicity, and weight status. This included a general pattern of lower preference ratings among girls (versus boys) and sexual minority (versus heterosexual) youth, and stronger preferences for words such as "thick" or "curvy" among racial/ethnic minority, sexual minority, and higher-weight youth. Use of most weight terms was higher among fathers compared with mothers, and by Hispanic/Latinx parents compared with white and Black/African American parents.

CONCLUSIONS

Our findings underscore diversity of youth preferences and the need for individualized approaches that support effective parent and youth communication by using their preferred terms when discussing weight-related health.

Motivations for engaging in or avoiding conversations about weight: Adolescent and parent perspectives

BACKGROUND

Little is known about parent and adolescent motivations for engaging in weight communication.

OBJECTIVES

To assess parent and adolescent motivations for engaging in, or avoiding, weight communication, and whether these reasons differed across sex, race/ethnicity, weight, and engagement in weight management.

METHODS

Independent samples of parents (N = 1936) and unrelated adolescents (N = 2032) completed questionnaires assessing their agreement with different reasons they engage in, or avoid, parent-adolescent weight communication, using 7-point Likert scales (strongly-disagree to strongly-agree).

RESULTS

Parents, irrespective of sex, race/ethnicity, and child's weight status, expressed stronger motivations for engaging in weight communication in order for their child to feel good about his/her weight and body size compared to being motivated because a health professional raised their child's weight as a concern. Adolescent motivations for weight communication with parents stemmed from health concerns and worry about their weight; avoidance stemmed from feeling embarrassed, upset, or not wanting to obsess about weight. Differences emerged across sex and race/ethnicity but were most pronounced by weight status and weight management.

CONCLUSION

Parents and adolescents have different motivations for engaging in or avoiding weight communication. Protecting adolescents' emotional wellbeing and body esteem are viewed as reasons for both engaging in or avoiding weight communication.

Weight stigma and posttraumatic stress disorder symptoms in individuals seeking bariatric surgery

BACKGROUND

After bariatric surgery, some patients experience adverse psychiatric outcomes, including substance use, suicidality, and self-harm. These factors are commonly associated with posttraumatic stress disorder (PTSD) and related symptoms (PTSD-S) that develop following adverse childhood experiences (ACEs) and traumatic events. However, emerging evidence suggests that chronic discrimination also may contribute to PTSD-S. Weight-based discrimination is salient for people with obesity but has received little attention in relation to PTSD-S.

OBJECTIVE

Our study examined factors that may contribute to the link between experienced weight stigma (WS), which is common in individuals seeking bariatric surgery, and PTSD-S.

SETTING

Teaching hospital and surgical weight loss center in the United States.

METHODS

A total of 217 participants completed self-report surveys of experienced and internalized WS, ACEs, and PTSD-S. Demographics and trauma history were obtained from patient medical records. A stepwise multiple regression examined associations between experienced WS and internalized WS with PTSD-S, co-varying demographics, ACEs, and trauma, followed by examination of whether findings held co-varying anxiety/depressive symptoms in a participant subset (n = 189).

RESULTS

After accounting for covariates in step 1 and ACEs and trauma in step 2 (ΔR² = .14), experienced WS and internalized WS accounted for substantial PTSD-S variance in steps 2 and 3 (ΔR² = .12 and .13, respectively; overall model R² =.44; P < .001). Findings held after co-varying anxiety/depressive symptoms.

CONCLUSIONS

Over and above ACEs and trauma, experienced WS and internalized WS may contribute to PTSD-S. Longitudinal research is needed to better elucidate the pathways underlying these associations.

Sexual and gender minority (SGM) adolescents' disordered eating: Exploring general and SGM-specific factors

OBJECTIVE

Sexual and gender minority (SGM) adolescents disproportionately report disordered eating, yet have primarily been considered under a larger SGM umbrella. The current study 1) compared disordered eating between sexual minority (SM) and gender minority (GM) adolescents; 2) examined how general psychological factors (self-esteem, depression, and stress) and SGM-specific factors (e.g., feelings about SGM identity, access to SGM resources) were associated with disordered eating; and 3) examined whether associations between these factors differed for SM versus GM adolescents.

METHOD

SGM adolescents in the U.S. (N = 8814; 35.0% GM; 43.7% cisgender girls; 66.9% White; M_age  = 15.6) reported their disordered eating, depressive symptoms, stress, self-esteem, and SGM-related experiences on an anonymous, cross-sectional online survey.

RESULTS

GM adolescents exhibited a higher prevalence of clinical threshold disordered eating than SM adolescents. Self-esteem was associated with lower odds of caloric restriction, purging, and binge eating. Depression was associated with higher odds of caloric restriction, diet pill use, purging, laxatives, and binge eating. Stress was associated with higher odds of purging. Associations were stronger for GM adolescents' caloric restriction. Positive feelings about SGM identity were associated with lower odds of caloric restriction, purging, and binge eating, whereas greater stress of "coming out" was associated with higher odds of caloric restriction, purging, and binge eating.

DISCUSSION

These results suggest that SGM adolescents' disordered eating is associated with both general psychological factors and unique SGM experiences. Results highlight the importance of considering how the unique experiences of SGM youth may leave them vulnerable to disordered eating behaviors.

PUBLIC SIGNIFICANCE STATEMENT

Sexual and gender minority (SGM) youth are disproportionately affected by disordered eating. The current study found that higher depression and stress, and lower self-esteem, were associated with SGM adolescents' disordered eating. Furthermore, unique SGM experiences, such as stress about coming out, were also associated with eating pathology. Results highlight the importance of considering SGM adolescents' perceptions of their identity and social support.

Weight-based cybervictimization: Implications for adolescent health

BACKGROUND

Despite the ubiquity of cybervictimization among youth, attention to weight-based cybervictimization is scarce.

AIMS

This study assessed the prevalence of electronic forms of weight-based peer victimization (i.e., cybervictimization) and its associations with adolescent health, as indicated by somatic symptoms, stress, depression, and sleep trouble.

MATERIALS & METHODS

A cross-sectional survey was conducted online with a community sample of 452 adolescents aged 11-17 years old (M_age  = 14.91 years).

RESULTS

Thirty-three percent of adolescents reported at least one experience of weight-based cybervictimization, with elevated rates among those with overweight (45%) and obesity (60%). Weight-based cybervictimization was associated with higher levels of somatic symptoms (β = 0.24; p < 0.001), stress (β = 0.22; p < 0.001), depression (β = 0.27; p < 0.001), and sleep trouble (β = 0.20; p < 0.001); these associations were consistent across adolescent weight status.

DISCUSSION AND CONCLUSION

Findings suggest that the health implications of weight-based victimization extend to the electronic context, and underscore the importance of addressing weight-based cybervictimization in antibullying initiatives to support healthy adolescent well-being.

A Comprehensive Examination of the Nature, Frequency, and Context of Parental Weight Communication: Perspectives of Parents and Adolescents

Research suggests that many parents make comments about their child’s weight, which is associated with negative adolescent health outcomes. Gaps in this literature include an underrepresentation of fathers, limited knowledge regarding positive versus negative parental weight comments and differences across race/ethnicity, and adolescent preferences for parental weight communication. The present study addressed these research gaps through a comprehensive investigation of two diverse samples of U.S. parents (n = 1936) and adolescents (n = 2032), who completed questionnaires about their experiences and perspectives of parental weight communication. Positive weight comments from parents were more frequent than negative comments, though both were commonly reported across sex, race/ethnicity, and weight status. In general, boys, fathers, Latino/a parents and adolescents, and adolescents with a high BMI and/or engaged in weight management reported more frequent parental weight-talk. Parent–adolescent weight communication occurred both in-person and digitally, and across daily life contexts. Although the majority of parents communicated positive messages of body diversity and respect, 44% and 63% of adolescents said they never want their mothers and fathers, respectively, to talk about their weight. Adolescents were offered circumstances that would increase their comfort level in having these conversations. Findings have implications for health professionals working with families to promote supportive health communication at home.

Weight stigma, policy initiatives, and harnessing social media to elevate activism

Efforts to promote positive body image and body acceptance confront considerable challenges in the face of pervasive societal stigma against people who have a high body weight or large body size. Despite decades of evidence documenting the prevalence and harmful consequences of weight stigma and discrimination, policies to address this social injustice are lacking and primarily absent. This article summarizes the current status of policies to address societal weight-based mistreatment and highlights evidence documenting public support for different types of policies and laws that could be implemented to reduce weight-based bullying and discrimination. While considerable public policy support is present, efforts to scale up activism are needed to help curtail societal weight stigma. Social media has been an underutilized approach that could provide a powerful platform to elevate public awareness and promote policy change to help eliminate weight stigma.

Experienced weight stigma, internalized weight bias, and clinical attrition in a medical weight loss patient sample

Background

Limited research has explored the relationship between weight bias and clinical attrition, despite weight bias being associated with negative health outcomes.

Participants/method

Experienced weight stigma (EWS), internalized weight bias (IWB), and clinical attrition were studied in a Medical Weight Loss clinic, which combines pharmacological and behavioral weight loss. Patient sociodemographic, medical, and psychological (depression) variables were measured at consultation, and clinic follow-ups were monitored for 6 months. IWB was assessed with the Weight Bias Internalization Scale Modified (WBIS-M).

Results

Two-thirds (66%) of study participants returned for follow-up appointments during the 6-month period (“continuers”), while 34% did not return after the initial consultation (“dropouts”). Clinic “dropouts” had higher WBIS-M scores at initial consultation than “continuers,” (χ²(1) = 4.56; p < 0.05). No other variables were related to clinical attrition. Average WBIS-M scores (4.57) were similar to other bariatric patient studies, and were associated with younger age (t = −2.27, p < 0.05), higher depression (t = 2.65, p < 0.01), and history of EWS (t = 2.14, p < 0.05).

Conclusion

Study findings indicate that IWB has significant associations with clinical attrition. Additional research is warranted to further explore the relationships between EWS, IWB, and medical clinic engagement.

Weight Stigma and Diabetes Stigma: Implications for Weight-Related Health Behaviors in Adults With Type 2 Diabetes

There has been little recognition that people with type 2 diabetes are vulnerable to weight stigma and diabetes stigma and almost no research examining the implications of these forms of stigma for their health and well-being. This study examined health behavior correlates of weight stigma and diabetes stigma in 1,227 adults with type 2 diabetes. Results showed that experiencing weight stigma in health care, experiencing differential treatment from others because of their diabetes, and engaging in self-stigma for diabetes and body weight were each significantly associated with increased frequency of binge eating and eating as a coping strategy to deal with negative feelings. Internalizing weight stigma was also significantly associated with lower levels of physical activity and worse self-rated health. These findings suggest that initiatives to improve the health and well-being of people with type 2 diabetes must consider the potentially harmful roles of weight stigma and diabetes stigma.

"There's Nothing Wrong With You": Pain-Related Stigma in Adolescents With Chronic Pain

OBJECTIVE

Adolescents with chronic pain often experience symptom disbelief and social rejection by others secondary to "medically unexplained" symptoms. Although chronic pain is common in adolescents, limited research has conceptualized these social experiences as pain-related stigma in this population. The purpose of this study was to identify and describe pain-related stigma among adolescents with chronic pain and their parents using focus group methodology.

METHODS

Five adolescent focus groups (N = 18; Age M = 15.33 years, SD = 1.28) and three parent focus groups (N = 9) were conducted. Directed content analysis was used to analyze focus group transcripts. Stigma categories were developed a priori (Felt Stigma, Anticipated Stigma, Internalized Stigma, Concealment, and Controllability) and new categories emerged during analysis. Two coders reached 87.16% agreement for all groups (adolescent group: 90.34%; Parent group: 79.55%) and consensus was achieved for discordant codes.

RESULTS

Adolescents and their parents endorsed pain-related stigma across all social domains. Analyses revealed four main categories for both groups (a) Felt Stigma (subcategories: pain dismissal, faking or exaggerating, and mental health stigma), (b) Anticipated Stigma and Concealment, (c) Internalized Stigma, and (d) Sources of Pain-Related Stigma (subcategories: pain invisibility, lack of chronic pain knowledge, lack of understanding, and controllability).

CONCLUSIONS

Adolescents with chronic pain experience pain-related stigma from medical providers, school personnel, family members, and peers, which may have negative social and health implications. More research is needed to evaluate the link between pain-related stigma and health outcomes for adolescents with chronic pain. Clinical approaches targeting pain-related stigma are discussed.

Policies to address weight discrimination and bullying: Perspectives of adults engaged in weight management from six nations

OBJECTIVE

Across the world, it remains legal to discriminate against people because of their weight. Although US studies demonstrate public support for laws to prohibit weight discrimination, multinational research is scarce. The present study conducted a multinational comparison of support for legislative measures to address weight discrimination and bullying across six countries.

METHODS

Participants were adults (n = 13,996) enrolled in an international weight-management program and residing in Australia, Canada, France, Germany, the UK, and the US. Participants completed identical online surveys that assessed support for antidiscrimination laws and policies to address weight bullying, demographic characteristics, and personal experiences of weight stigma.

RESULTS

Across countries, support was high for laws (90%) and policies (92%) to address weight-based bullying, whereas greater between-country variation emerged in support for legislation to address weight-based discrimination in employment (61%, 79%), as a human rights issue (57%), and through existing disability protections (47%). Findings highlight few and inconsistent links between policy support and sociodemographic correlates or experienced or internalized weight stigma.

CONCLUSIONS

Support for policies to address weight stigma is present among people engaged in weight management across Westernized countries; findings offer an informative comparison point for future cross-country research and can inform policy discourse to address weight discrimination and bullying.

Reducing Educators' Weight Bias: The Role of School-Based Anti-Bullying Policies

BACKGROUND

Educators' negative weight biases toward students with high body weight have been well-documented. The present investigation examined whether inclusion of body weight in school anti-bullying policies is associated with lower levels of weight bias among educators.

METHODS

Data on explicit weight bias was collected from a sample of secondary school teachers and principals in the United States (N = 246) and examined in relation to the presence of weight-related language in each participant's school district anti-bullying policy.

RESULTS

The results indicate that, although educators on average make negative judgments about individuals with high weight, these biases were lower for educators whose school district anti-bullying policy included enumeration of body weight. Notably, this association did not hold when policies enumerated "appearance."

CONCLUSIONS

The study findings suggest that the explicit mention of "weight" in school anti-bullying policies may represent a feasible mechanism to reduce explicit weight bias among U.S. secondary school educators.

Weight Stigma and Weight-Related Health: Associations of Self-Report Measures Among Adults in Weight Management

BACKGROUND

Weight stigma impairs health. Few studies have disentangled the associations of experienced versus internalized stigma with weight-related outcomes.

PURPOSE

To examine weight and health variables associated with weight stigma experiences and internalization in the largest-to-date sample of adults in weight management.

METHODS

WW (formerly Weight Watchers) members (N = 18,769, 94.6% female, 91.1% white) completed an online survey from 2017 to 2018. Participants reported whether they had experienced weight stigma and, if so, the onset, past-year frequency and distress, and interpersonal sources of stigma. Participants completed the Modified Weight Bias Internalization Scale (WBIS-M) and self-reported: past-year weight and lifetime weight cycles; current self-monitoring behaviors; eating self-efficacy; physical activity; perceived stress; eating to cope; body image; and mental and physical health-related quality-of-life (HRQOL). Participants reported their demographic characteristics, including height and weight to compute body mass index.

RESULTS

In logistic and linear regression analyses (controlling for participant characteristics), WBIS-M scores were negatively associated with weight loss, self-monitoring, eating self-efficacy, body image, and mental HRQOL and positively associated with weight gain, weight cycling, perceived stress, and eating to cope (p < .001). Experiencing weight stigma was associated with greater weight loss and less weight gain, although associations with other variables had small effect sizes (absolute β values < 0.10). WBIS-M scores remained significantly associated with all variables when including stigma onset, frequency/distress, and sources.

CONCLUSIONS

Internalized, but not experienced, weight stigma was consistently associated with adverse weight and health factors. Developing and testing interventions targeting internalized stigma in the context of weight management should be a research priority.

International comparisons of weight stigma: addressing a void in the field

BACKGROUND/OBJECTIVES

Despite substantial evidence documenting weight stigma toward people with higher body weight, international comparative studies are lacking in this field. The few studies that have compared weight stigma across different countries focus on explicit weight-biased attitudes rather than people's experiences of weight stigma. The present study conducted a multinational systematic comparison of weight stigma in six countries to assess experiences and interpersonal sources of weight stigma.

SUBJECTS/METHODS

Adults (N = 13,996) enrolled in WW International (formerly Weight Watchers), residing in Australia, Canada, France, Germany, the UK, and the US completed identical online anonymous surveys in the dominant language for their country. Surveys assessed their history of experiencing weight stigma, the onset of stigmatizing experiences and associated distress from stigma in different time periods, and interpersonal sources of weight stigma.

RESULTS

More than half of participants (55.6-61.3%) across countries reported experiencing weight stigma. Participants with higher BMI were significantly more likely to report weight-stigmatizing experiences than individuals with lower BMI. In all countries, weight stigma experiences were most frequent in childhood and adolescence, with associated distress highest during these time periods. Participants in Germany reported a higher frequency of weight stigma across their whole life, but lower distress associated with stigmatizing experiences, compared to participants in the other five countries. High percentages of participants in each country experienced weight stigma from family members (76.0-87.8%), classmates (72.0-80.9%), doctors (62.6-73.5%), co-workers (54.1-61.7%), and friends (48.8-66.2%).

CONCLUSIONS

Weight stigma is prevalent for adults actively engaged in weight management across different Western countries. There were more similarities than differences in the nature, frequency, and interpersonal sources of people's experiences of weight stigma across the six countries in this study. Findings underscore the need for multinational initiatives to address weight stigma and interventions to support individuals engaged in weight management who experience weight mistreatment.

Adolescents' Exposure to and Experiences of Weight Stigma During the COVID-19 Pandemic

OBJECTIVE

The COVID-19 pandemic has increased attention to the proliferation of pediatric obesity amidst significant changes in weight-related health functioning (e.g., compromised physical activity, limited food access, increased stress). The present cross-sectional study investigated adolescents' feelings about their bodies and perceived changes in weight stigma from peers, parents, and social media during the pandemic.

METHODS

Four hundred fifty-two adolescents (11-17 years old) completed an online survey during the Fall of 2020. Measures assessed perceived changes in exposure to weight stigmatizing social media content (stress eating jokes, weight gain memes) and experiences of weight stigma (weight-based bullying, teasing, hurtful comments) by parents and peers, as well as body dissatisfaction, during the COVID-19 pandemic. Weight status and gender were examined as individual difference variables.

RESULTS

The majority (53%) of adolescents reported increased exposure to at least one form of weight stigmatizing social media content during the pandemic. Additionally, pandemic-related increases in body dissatisfaction were prevalent (41%), especially among girls with higher body mass index (≥85th percentile; 67%). On average, the extent to which adolescents experienced weight-based mistreatment from parents and peers remained consistent with their pre-pandemic experiences.

CONCLUSIONS

Overall, these findings highlight changes in the social messages that adolescents receive about their bodies, as well as their subjective body satisfaction, during the pandemic. Results underscore the need for healthcare providers and mental health professionals to be aware of the potential rise in weight stigma during the pandemic, and encourage families and schools to engage in supportive, rather than stigmatizing, weight-related communication with youth.

The role of weight bias and role-modeling in medical students' patient-centered communication with higher weight standardized patients

OBJECTIVE

Patients with obesity may experience less patient-centered care. We assessed whether medical students' implicit/explicit weight-related attitudes and perceptions of normative attitudes are associated with patient-centered care for patients with obesity.

METHODS

Third and fourth year medical students (N = 111) at one medical school completed a survey and participated in a patient care scenario with a standardized patient with obesity. Encounters were coded for patient-centered behavior. Predictors of patient-centered behaviors were assessed.

RESULTS

Student perceptions that negative attitudes about patients with obesity are normative in medical school were significantly associated with poorer patient-centered behaviors, including lower attentiveness (b=-0.19, p = 0.01), friendliness (b=-0.28, p < 0.001), responsiveness (b=-0.21, p = 0.002), respectfulness (b=-0.17, p = 0.003), interactivity (b=-0.22, p = 0.003), likelihood of being recommended by observers (b=-0.34, p < 0.001), and patient-centeredness index scores (b=-0.16, p = 0.002). Student reported faculty role-modeling of discrimination against patients with obesity predicted lower friendliness (b=-0.16, p = 0.03), recommendation likelihood (b=-0.22, p = 0.04), and patient-centeredness index score (b=-0.12, p = 0.03).

CONCLUSIONS

Negative normative attitudes and behaviors regarding obesity in the medical school environment may adversely influence the quality of patient-centered behaviors provided to patients with obesity.

PRACTICE IMPLICATIONS

Efforts to improve patient-centered communication quality among medical trainees may benefit from intervention to improve group normative attitudes about patients with obesity.

Adolescent academic worries amid COVID-19 and perspectives on pandemic-related changes in teacher and peer relations

Despite recognition of the potential impact of the COVID-19 pandemic on secondary schooling experiences, little empirical evidence has captured adolescents' perspectives on the extent of academic and social disruption resulting from the pandemic. The present study examined adolescents' academic worries amid the COVID-19 pandemic and their perspectives on pandemic-related changes in teacher and peer relations. Participants were 452 adolescents (55% female) between the ages of 11 and 17, who completed online surveys asking them about their worries about their schoolwork and educational futures, perceived support from teachers, and perceptions of electronic (cyber) bullying during the pandemic. Results indicated that COVID-related academic worries pertaining to motivation to focus on and complete schoolwork were most frequent. High school students and female students reported heightened academic worries compared to middle school students and male students. In addition, the majority of adolescents indicated decreased support from teachers during the COVID-19 pandemic, including more than two-thirds (69%) who reported reduced communication with teachers. Adolescents perceived relative consistency in electronic (cyber) bullying throughout the pandemic, and a third of students indicated that cyberbullying has become more of a problem and increased in frequency during this time period. Perceived changes in cyberbullying were consistent across grade level and gender. Findings emphasize the psychosocial implications of the COVID-19 pandemic on adolescents' secondary schooling experiences and underscore the importance of bolstering social resources to minimize the short- and long-term impact of the pandemic on students' academic functioning. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Parental Contributors to the Prevalence and Long-term Health Risks of Family Weight Teasing in Adolescence

PURPOSE

Weight teasing from family members is common during adolescence. However, little is known about parental factors that increase adolescents' risk for family weight teasing and its adverse health sequelae. Using multi-informant data from adolescents, mothers and fathers, the current longitudinal study examined how parental concerns about their child's weight and their own weight contribute to family weight teasing in adolescence and its long-term health consequences.

METHODS

Data were collected in the population-based Project EAT 2010-2018 (Eating and Activity over Time) study, following a longitudinal cohort of young people (N = 2,793). Parental weight concerns for their adolescent and themselves were reported by mothers (N = 2,298) and fathers (N = 1,409) at baseline and examined as a predictor of family weight teasing in adolescence as well as a moderator of family weight teasing effects on health eight years later.

RESULTS

Mothers' and fathers' concerns about their child's weight, as well as mothers' dieting frequency, increased the likelihood of adolescents experiencing family weight teasing. Longitudinal analyses revealed that adolescents teased about their weight by family had higher levels of stress (β = .21, 95% confidence interval [CI] = .09-.33) and substance use (β = .16, 95% CI = .04-.28), and lower self-esteem (β = -.16, 95% CI = -.28 to -.05) in young adulthood.

CONCLUSIONS

Findings highlight parent weight concern, particularly concern for their child's weight, as a risk factor for family weight teasing. These findings underscore the importance of encouraging parental attention to health, rather than weight, in family-based treatment and public health initiatives.

"If It Ever Really Hurts, I Try Not to Let Them Know:" The Use of Concealment as a Coping Strategy Among Adolescents With Chronic Pain

Objective

Despite considerable evidence of chronic pain in adolescents, and its adverse consequences for their health and well-being, less is known about pain-related stigma that these youth face, such as pain disbelief by others. Adolescents with chronic pain may conceal their symptoms as a coping strategy to avoid pain-related stigma, contributing to further social isolation and disruptions in medical treatment. In the current study, we used focus group methodology to examine adolescent motivations for using concealment and the possible benefits and harmful consequences of this form of coping.

Materials and Methods

Five focus groups of 3–5 adolescents (ages 12–17) with chronic pain conditions (N = 18) were conducted as a part of a larger study to evaluate the impact of, and reaction to, pain-related stigma. Patients were recruited from an outpatient pediatric pain management clinic. Transcripts of focus group sessions were analyzed using directed content analysis for the main study, yielding anticipatory stigma and concealment categories. These categories were then explored using inductive content analysis for the current study.

Results

Adolescents described engaging in concealment of their pain symptoms. Our analysis revealed three social motivations for concealment: (1) avoidance of judgment; (2) avoidance of being a social burden; and (3) desire to be treated normally, and two harmful consequences of concealment: (1) social isolation and (2) cognitive burden.

Conclusion

Disbelief of pain symptoms may exacerbate the social isolation and disease-related burden in this population. Clinical implications of concealing pain symptoms are discussed, and points of intervention are proposed.

Eating and Exercise-Related Correlates of Weight Stigma: A Multinational Investigation

OBJECTIVE

Weight stigma is prevalent across the world. However, little is known about whether and how the harmful health consequences of weight stigma may vary across countries. The current study examined the association between experiences of weight stigma and multiple eating and exercise-related indicators among a large, multinational sample of adults.

METHODS

Adults enrolled in an international weight management program residing in Australia, Canada, France, Germany, the United Kingdom, and the United States completed identical Web-based surveys in the dominant language for their country. Participants (N = 13,996) reported on their personal experiences of weight stigma and health, including eating behaviors, attitudes toward exercise, and perceived stress.

RESULTS

More than half of all participants in each country reported experiencing weight stigma. Participants who had experienced weight stigma reported engaging in more eating to cope, gym avoidance, and self-monitoring behaviors, as well as higher levels of stress and reduced eating self-efficacy. These associations were documented over and above sociodemographic characteristics and BMI and did not vary across countries.

CONCLUSIONS

Study findings document uniform health-related correlates of weight stigma within a multinational context and underscore the need for global initiatives to curtail weight stigma in order to support population health.

The roles of experienced and internalized weight stigma in healthcare experiences: Perspectives of adults engaged in weight management across six countries

BACKGROUND/OBJECTIVES

Considerable evidence from U.S. studies suggests that weight stigma is consequential for patient-provider interactions and healthcare for people with high body weight. Despite international calls for efforts to reduce weight stigma in the medical community, cross-country research is lacking in this field. This study provides the first multinational investigation of associations between weight stigma and healthcare experiences across six Western countries.

METHODS

Participants were 13,996 adults residing in Australia, Canada, France, Germany, the UK, and the US who were actively enrolled in an internationally available behavioral weight management program. Participants completed identical online surveys in the dominant language for their country that assessed experienced weight stigma, internalized weight bias, and healthcare behaviors and experiences including perceived quality of care, avoidance or delay of seeking care, experiences with providers, and perceived weight stigma from doctors.

RESULTS

Among participants who reported a history of weight stigma (56-61%), two-thirds of participants in each country reported experiencing weight stigma from doctors. Across all six countries, after accounting for demographics, BMI, and experienced stigma, participants with higher internalized weight bias reported greater healthcare avoidance, increased perceived judgment from doctors due to body weight, lower frequency of obtaining routine checkups, less frequent listening and respect from providers, and lower quality of healthcare. Additionally, experienced weight stigma (from any source) was indirectly associated with poorer healthcare experiences through weight bias internalization, consistently across the six countries.

CONCLUSIONS

Weight stigma in healthcare is prevalent among adults actively engaged in weight management across different Western countries, and internalized weight bias has negative implications for healthcare even after controlling for BMI. The similar findings across all six countries underscore the negative consequences of weight stigma on healthcare behaviors and experiences, and emphasize the need for collective international efforts to address this problem.

Shame and Self-compassion as Risk and Protective Mechanisms of the Internalized Weight Bias and Emotional Eating Link in Individuals Seeking Bariatric Surgery

BACKGROUND

Emotional eating in bariatric surgery patients is inconsistently linked with poor post-operative weight loss and eating behaviors, and much research to date is atheoretical. To examine theory-informed correlates of pre-operative emotional eating, the present cross-sectional analysis examined paths through which experienced weight bias and internalized weight bias (IWB) may associate with emotional eating among individuals seeking bariatric surgery.

METHODS

We examined associations of experienced weight bias, IWB, shame, self-compassion, and emotional eating in patients from a surgical weight loss clinic (N = 229, 82.1% female, M. BMI: 48 ± 9). Participants completed a survey of validated self-report measures that were linked to BMI from the patient medical record. Multiple regression models tested associations between study constructs while PROCESS bootstrapping estimates tested the following hypothesized mediation model: IWB ➔ internalized shame ➔ self-compassion ➔ emotional eating. Primary analyses controlled for adverse childhood experiences (ACE), a common confound in weight bias research. Secondary analyses controlled for depressive/anxiety symptoms from the patient medical record (n = 196).

RESULTS

After covariates and ACE, each construct accounted for significant unique variance in emotional eating. However, experienced weight bias was no longer significant and internalized shame marginal, after controlling for depressive/anxiety symptoms. In a mediation model, IWB was linked to greater emotional eating through heightened internalized shame and low self-compassion, including after controlling for depressive/anxiety symptoms.

CONCLUSIONS

Pre-bariatric surgery, IWB may signal risk of emotional eating, with potential implications for post-operative trajectories. Self-compassion may be a useful treatment target to reduce IWB, internalized shame, and related emotional eating in bariatric surgery patients. Further longitudinal research is needed.

Examining the relationship between weight controllability beliefs and eating behaviors: The role of internalized weight stigma and BMI

Body weight is often viewed as personally controllable. This belief, however, ignores the complex etiology of body weight. While such attributions of personal willpower may help some individuals regulate their eating patterns, they have also been associated with increased internalized weight stigma which, itself, is associated with more disinhibited eating. The current investigation aimed to examine how internalized weight stigma, along with BMI, may explain the effect of weight controllability beliefs on disparate dietary behaviors. A community sample of 2702 U.S. adults completed an online survey about their weight controllability beliefs, eating behaviors, and internalized weight stigma, as well as demographic items and self-reported BMI. Results showed that greater weight controllability beliefs were positively related to both more restricted eating, β = 0.135, p < .001, and more disinhibited eating, β = 0.123, p < .001. This ironic effect was partially explained by increased internalized weight stigma. Moreover, BMI moderated the relationship, such that individuals with lower weights demonstrated stronger effects for two of the three eating outcomes than those with higher weights. These findings advance our understanding of the relationship between attributions of personal control for body weight and subsequent health behaviors, and further underscore the need to target internalized weight stigma in dietary interventions.

Prevalence and correlates of weight bias internalization in weight management: A multinational study

Weight bias internalization (WBI) is an understudied form of internalized stigma, particularly among treatment-seeking adults with overweight/obesity. The current study surveyed 13,996 adults currently engaged in weight management in the first multinational study of WBI. From May to July 2020, participants in six Western countries completed the Modified Weight Bias Internalization Scale (WBIS-M) and measures of weight change, health behaviors, psychosocial well-being, and health-related quality of life (HRQOL). Participants were majority white, female, middle-aged, and categorized as having overweight or obesity based on body mass index. Results showed higher mean WBIS-M scores among participants in the UK, Australia, and France than in Germany, the US, and Canada. Across all countries, and controlling for participant characteristics and experiences of weight stigma, WBIS-M scores were associated with greater weight gain in the past year. Participants with higher WBIS-M scores also reported poorer mental and physical HRQOL, less eating and physical activity self-efficacy, greater engagement in eating as a coping strategy, more avoidance of going to the gym, poorer body image, and greater perceived stress. Few interaction effects were found between experiences and internalization of weight stigma. Overall, the current findings support WBI as a robust correlate of adverse weight-related health indices across six Western countries. Prospective and experimental studies are needed to determine directionality and causality in the relationship between WBI and poor health outcomes.

•

Differences in weight bias internalization (WBI) were found between six Western countries.

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WBI was associated with weight gain in the past year across countries.

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WBI was associated with adverse weight-related health indices across countries.

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Associations with weight and health were stronger for WBI than weight stigma experiences.

Weight stigma as a psychosocial contributor to obesity

Weight stigma is a key aspect of the lived experience of individuals with obesity, and adversely affects health. This article provides an overview of recent evidence examining links between experiences of weight stigma and weight-related behaviors and health (e.g., maladaptive eating, physical activity, stress, obesity, weight loss), including health consequences for individuals with heightened vulnerability to weight stigma (e.g., youth and people seeking bariatric surgery) and implications for clinicians working with individuals who have obesity. This literature points to weight stigma as a psychosocial contributor to obesogenic behaviors, yet the role of weight stigma in weight loss among treatment-seeking individuals has received little attention. Research priorities are identified, including the need for future studies to (a) determine the potentially predictive value of specific characteristics of weight-stigmatizing experiences for weight loss (such as the time period, interpersonal sources, and coping responses for stigma experiences), (b) identify mechanisms through which weight stigma may undermine or facilitate weight-related treatment outcomes, and (c) test strategies that can be implemented in weight management programs to reduce the negative impact of weight stigma on health behaviors. Broadly, more attention should be directed to weight stigma in the obesity field as a relevant psychosocial factor in obesity-focused prevention and treatment. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

At multiple fronts: Diabetes stigma and weight stigma in adults with type 2 diabetes

AIM

The diabetes and obesity fields have called for attention to the harmful role of stigma in obesity and diabetes, especially given that little is known about the extent and nature of diabetes stigma facing adults with type 2 diabetes, or the experience of weight stigma in this population. This study addresses this research gap by examining the prevalence and demographic correlates of weight stigma and diabetes stigma in individuals with type 2 diabetes.

METHODS

Adults (N = 1212, M_age  = 52) with type 2 diabetes living in the USA were recruited by a healthcare-oriented market research firm, and completed online questionnaires to assess their experiences with weight stigma and diabetes stigma, as well as their internalization of both forms of stigma. Rates of stigma and sociodemographic correlates (years with type 2 diabetes, age, education, income, gender, race and BMI) were examined.

RESULTS

More than half of participants reported prior experiences of weight stigma, and 40-60% reported experiencing weight stigma in a healthcare context. Participants reported frequent experiences with diabetes-related stigma including blame and judgement, self-stigma and differential treatment. Women reported more weight stigma than men, and White women appeared particularly at risk for experiencing weight and diabetes related stigma relative to Black women.

CONCLUSIONS

Individuals with type 2 diabetes reported higher rates of weight stigma than the general population, experienced high rates of diabetes-related stigma, and many internalized these forms of stigma. Increased attention to stigma reduction is essential to ensuring equitable care for individuals with type 2 diabetes.

Weight Stigma in Youth: Prevalence, Consequences, and Considerations for Clinical Practice

PURPOSE OF REVIEW

This review summarizes recent evidence on weight stigma experienced by youth with overweight or obesity. We examine the prevalence and sources of weight-based victimization targeting youth, consequences of these stigmatizing experiences for their psychological and physical health, and considerations for addressing weight stigma in clinical practice and pediatric care.

RECENT FINDINGS

Weight stigma is highly prevalent among youth with high body weight, who are targets of weight-based victimization from peers, parents, and teachers. These experiences place youth at risk for psychological distress (primarily depressive symptoms, low self-esteem, and suicidal ideation), worse social and academic outcomes, and adverse physical health consequences including maladaptive eating behaviors, lower physical activity, substance use, and weight gain. Healthcare professionals and clinicians have important roles to play in efforts to help reduce weight stigma and support youth with obesity. Fundamental to these efforts is the use of supportive, compassionate, and non-stigmatizing communication with youth and their families.

Weight Stigma as a Predictor of Distress and Maladaptive Eating Behaviors During COVID-19: Longitudinal Findings From the EAT Study

Background

Weight stigma is common for people with obesity and harmful to health. Links between obesity and complications from COVID−19 have been identified, but it is unknown whether weight stigma poses adverse health implications during this pandemic.

Purpose

We examined longitudinal associations between prepandemic experiences of weight stigma and eating behaviors, psychological distress, and physical activity during the COVID-19 pandemic in a diverse sample of emerging adults.

Methods

Participants (N = 584, 64% female, mean age = 24.6 ± 2.0 years, mean body mass index [BMI] = 28.2) in the COVID-19 Eating and Activity over Time (C-EAT) study were cohort members of the population-based longitudinal study EAT 2010–2018. Weight stigma reported by participants in 2018 was examined as a predictor of binge eating, eating to cope, physical activity, depressive symptoms, and stress during COVID-19. Data were collected via online surveys during the U.S. outbreak of COVID-19 in 2020.

Results

Prepandemic experiences of weight stigma predicted higher levels of depressive symptoms (β = 0.15, p < .001), stress (β = 0.15, p = .001), eating as a coping strategy (β = 0.16, p < .001), and an increased likelihood of binge eating (odds ratio = 2.88, p < .001) among young adults during the COVID-19 pandemic but were unrelated to physical activity. Although associations remained after accounting for demographic characteristics and BMI, the magnitude of longitudinal associations was attenuated after adjusting for prior levels of the outcome variables.

Conclusions

Young adults who have experienced weight stigma may have increased vulnerability to distress and maladaptive eating during this pandemic. Public health messaging could be improved to support people of diverse body sizes and reduce the harmful consequences of weight stigma.

Weight stigma and diabetes stigma in U.S. adults with type 2 diabetes: Associations with diabetes self-care behaviors and perceptions of health care

AIMS

Diabetes stigma and weight stigma have been identified as important but neglected issues that warrant attention among people with type 2 diabetes. This study assessed associations of diabetes stigma and weight stigma with diabetes self-care behaviors and health care in adults with type 2 diabetes.

METHODS

U.S. adults with type 2 diabetes (N = 1,227) completed self-report questionnaires to assess their experiences of weight stigma, diabetes stigma, diabetes self-management, diabetes-specific distress, healthcare utilization, perceptions of diabetes-specific health care. They also provided sociodemographic information. Linear regressions examined relationships among stigma and diabetes self-care and related health care, controlling for participants' age, education, income, gender, race/ethnicity, and body mass index.

RESULTS

Internalized weight stigma and diabetes self-stigma were both significantly associated with higher diabetes-specific distress. Adults who expressed self-stigma for their diabetes reported less diabetes self-management and lower self-efficacy, and those who reported being judged about their weight by a doctor exhibited greater diabetes-specific distress. While a history of experienced weight stigma (in general) did not reduce frequency of seeking health care, lower quality interactions with health care professionals were reported by adults who expressed diabetes self-stigma and those who experienced weight stigma from a doctor.

CONCLUSIONS

Self-stigma for diabetes and body weight, as well as experiencing judgment about weight from doctors, may have negative implications for diabetes-specific self-care behaviors and perceived quality of health care. Efforts to promote wellbeing in individuals with type 2 diabetes need to consider reducing both diabetes and weight stigma and their potentially harmful consequences.

Weight Bias, Shame, and Self-Compassion: Risk/Protective Mechanisms of Depression and Anxiety in Prebariatic Surgery Patients

OBJECTIVE

Psychopathology in bariatric surgery patients may contribute to adverse postoperative sequelae, including weight regain, substance use, and self-harm. This cross-sectional study aimed to advance the understanding of the risk and protective paths through which weight bias associates with depressive and anxiety symptoms in bariatric surgery candidates (BSC).

METHODS

BSC recruited from a surgical clinic (N = 213, 82.2% women, 43  [SD 12] years, mean BMI: 49  [SD 9] kg/m² ) completed measures of experienced weight bias (EWB), internalized weight bias (IWB), body and internalized shame, and self-compassion; anxiety and depression screeners were accessed from medical charts. Multiple regression and PROCESS bootstrapping estimates tested our hypothesized mediation model as follows: EWB→IWB→body shame→shame→self-compassion→symptoms.

RESULTS

After accounting for EWB and IWB, internalized shame accounted for greater variance in both end points than body shame. EWB was associated with greater anxiety through risk paths implicating IWB, body shame, and/or internalized shame. Protective paths associated EWB with fewer depressive and anxiety symptoms among those with higher self-compassion.

CONCLUSIONS

The findings suggest a potentially important role for weight bias and shame in psychological health among BSC and implicate self-compassion, a trainable affect-regulation strategy, as a protective factor that may confer some resiliency. Future research using longitudinal and causal designs is warranted.

Trying again (and again): Weight cycling and depressive symptoms in U.S. adults

As the prevalence of overweight and obesity have risen over the past few decades, so have weight control attempts. Research has shown, however, that intentional weight loss results are often short-lived, with people regaining the weight over time. This can lead to weight cycling-losing and gaining weight repeatedly. Previous research, mostly done over two decades ago, concluded there was no relationship between weight cycling and psychological health. The goal of the current paper was to re-examine the relationship between weight cycling and depressive symptoms in a national sample of American adults (N = 2702; 50.7% female; mean age = 44.8 years). If, as hypothesized, there is a relationship between more frequent weight cycling and depressive symptoms, then internalized weight stigma will be examined as a potential mediator of the relationship. Results of a cross-sectional survey showed that 74.6% of adults report they have intentionally tried to lose weight. Amongst those who have tried to lose to weight, the average number of weight cycles over the lifetime was 7.82 cycles. Simultaneous regression showed that greater weight cycling was related to greater reported depressive symptoms (β = .15, p < .001), controlling for age, gender, education, income, and body mass index. Internalized weight stigma was a partial mediator of this relationship. Discussion focuses on the potential implications for weight cycling and mental health.

Gay-Straight Alliances: A Mechanism of Health Risk Reduction Among Lesbian, Gay, Bisexual, Transgender, and Questioning Adolescents

INTRODUCTION

Adolescents who identify as a sexual or gender minority are vulnerable to multiple health disparities because of stigma-based peer harassment. Given that sexual and gender minority adolescents may be bullied for several stigmatized identities that may exacerbate health risk, it is important to examine factors that can simultaneously reduce multiple forms of targeted victimization among sexual and gender minority adolescents. This study examines whether variation in health risk across sexual and gender minority adolescents who attend schools with versus without a gay-straight alliance can be explained by lessened bias-based bullying across a broad scope of stigmatized identities and attributes.

METHODS

Data on school-based gay-straight alliances, bias-based bullying, and health risk indicators were collected from the LGBTQ National Teen Survey (n=17,112; mean age=15.57 [SD=1.27] years) and analyzed in 2019. Multiple mediation analysis was conducted using latent variable structural equation modeling.

RESULTS

The majority (73%) of sexual and gender minority adolescents were bullied for stigmatized identities other than those related to their gender or sexual orientation. Compared to schools without a gay-straight alliance, student reports of multiple forms of bias-based bullying (based on body weight, gender, religion, disability, gender typicality, sexual orientation) were lower at schools with gay-straight alliances, which in turn attenuated adverse health outcomes (i.e., stress, sleep problems, depression, and unhealthy weight control behaviors).

CONCLUSIONS

Sexual and gender minority adolescents experience multiple forms of bias-based bullying, which independently heighten health risk, and this study extends previous work on gay-straight alliances to highlight a wider range of potential positive contributions to adolescent health.

Experiences of weight stigma and links with self-compassion among a population-based sample of young adults from diverse ethnic/racial and socio-economic backgrounds

OBJECTIVE

This study examines weight stigma experiences in a population-based sample of young adults from diverse ethnic/racial and socio-economic backgrounds, and explores cross-sectional associations between weight stigma and self-compassion, including gender differences in this relationship.

METHODS

Data come from EAT 2018, a population-based study of weight and related behaviors in young adults (N = 1523, mean age = 22 years, 53.5% females). Adjusted models tested associations between different experiences of weight stigma and the Self-Kindness Subscale of the Self-Compassion Scale, controlling for age, body mass index (BMI), ethnicity/race, and SES.

RESULTS

Over a third (32.3-52.2%) of participants reported experiences of weight teasing, and almost half (39.2-54.8%) indicated that people in their work or school settings are treated differently based on weight. There were few differences across ethnic/racial groups in reports of weight stigma. The prevalence of weight stigma experiences reported by participants in their current school or work environment was similar across gender, and those who had experienced weight stigma had lower levels of self-kindness. Among both females and males, lower self-kindness scores were associated with the experience of weight teasing (females: χ² = 22.6, df = 1, p < .001, d = 0.32; males χ² = 7.6, df = 1, p < .001, d = 0.22). For females only, lower self-kindness scores were associated with being treated unfairly due to weight (χ² = 11.1, df = 1, p < .001, d = 0.23), and having others make comments about your weight (χ² = 14.6, df = 1, p < .001, d = 0.28). Findings remained after adjusting for race/ethnicity, BMI, and SES.

CONCLUSION

Associations between self-compassion and experiences of weight stigma found in our diverse sample of young adults offers insights on this understudied relationship.