UNDERSTANDING OBESITY STIGMA AS A STRESSOR
ACROSS THE LIFECOURSE
SHARON BERNECKI DEJOY, PHD, MPH, CPH, CPM
WEST CHESTER UNIVERSITY OF PENNSYLVANIA
ACKNOWLEDGMENTS
 With thanks to:
 UConn Rudd Center for Food Policy and Obesity
 Janell Mensinger, PhD
Drexel University College of Nursing and Health Professions
 Emily Holladay
West Chester University of Pennsylvania BS Public Health-Health Promotion student
 Debra Mandel, PhD, RNC-OB
West Chester University of Pennsylvania College of Health Sciences
 Krystle Bittner, MPH
OBESITY IN PREGNANCY
EPIDEMIOLOGY
 Prevalence of pre-pregnancy overweight in women: 24.9%
 Prevalence of pre-pregnancy obesity: 22.1%
2009 PRAMS data (Robbins et al., 2014)
MATERNAL COMPLICATIONS OF OBESITY
 Miscarriage
 Hypertensive disorders
 Gestational Diabetes Mellitus (GDM)
 Preterm Birth
 Assisted Vaginal Delivery
 Stillbirth
 Cesarean delivery
 Wound infection
 Postpartum hemorrhage
 Anesthetic complications
 Increased length of stay in hospital
Galliano & Bellver, 2013
FETAL COMPLICATIONS
 Congenital Anomalies
 Fetal Distress
 Macrosomy
 Hydramnios
 Shoulder Dystocia
 Hypoglycemia
 Jaundice
Galliano & Bellver, 2013
POSTNATAL COMPLICATIONS
 Obesity
 Type 2 Diabetes
 Cancer
 Neurodevelopmental delay
Galliano & Bellver, 2013
EFFECTIVENESS OF INTERVENTIONS IN PREGNANCY
 Behavioral interventions reduced gestational weight gain by 3.6 pounds, on average,
among women with obesity, but not among overweight or severely obese women.
These interventions had no effect on length of gestation or infant birth weight, and
did not affect the woman’s postpartum weight status in any weight category.
 Postpartum/interconceptional weight loss is possible, but best practices are emerging.
Agha, Agha & Sandell, 2014; Nascimento et al., 2014; van der Pligt et al, 2013
EFFECTIVENESS OF WEIGHT LOSS INTERVENTIONS IN GENERAL
 Weight loss of 5% to 10% = success
 Only 10-20% can maintain a 10% a weight loss after 1 year
 10% loss is typical outcome of the best behavioral and/or
pharmacological treatments
 Significant weight loss is not readily sustainable with current
conventional treatment options
Wadden & Foster, 2000; Wing & Hill, 2001
MATERNAL OBESITY IS A PUBLIC HEALTH PROBLEM. WHY IS IT ADDRESSED THROUGH
LESS-THAN-EFFECTIVE INDIVIDUAL-LEVEL INTERVENTIONS?
THEORETICAL FRAMEWORKS IN MCH
LIFECOURSE FRAMEWORK, SOCIAL ECOLOGICAL MODEL, AND MULTIPLE DETERMINANTS
LIFE COURSE PERSPECTIVE-KEY CONCEPTS
 “Today’s experiences and exposures influence tomorrow’s health. (Timeline)
 Health trajectories are particularly affected during critical or sensitive periods.
(Timing)
 The broader community environment – biologic, physical, and social – strongly
affects the capacity to be healthy. (Environment)
 While genetic make-up offers both protective and risk factors for disease conditions,
inequality in health reflects more than genetics and personal choice. (Equity)”
U.S. Department of Health and Human Services, 2010, p. 4
SOCIAL ECOLOGICAL MODEL
Source: CDC
Figure 1 Women’s reproductive cycles.
Source: Misra, Guyer & Allston, (2003)
SOCIAL DETERMINANT: RACISM
 Consistent associations between perceptions of racial discrimination and preterm
birth, low birth weight, and very low birth weight in African-American women. (Earnshaw
et al., 2013; Giurgescu, McFarlin, Lomax, Craddock, & Albrecht, 2011)
 Structural racism places African-American populations at elevated risk for social and
economic disadvantage. (Mendez, Hogan, & Culhane, 2014).
 Interpersonal racism in daily life and health care encounters can provoke
psychosocial distress. (Williams,Yu, Jackson, & Anderson, 1997)
OBESITY STIGMA AS A SOCIAL DETERMINANT OF
HEALTH
WHAT IS STIGMA?
 Convergence of 5 processes
1.
Labeling of human differences occurs
2.
Individual is linked to undesirable characteristics (stereotyped)
3.
Separation of stigmatized others (“us” versus “them”)
4.
Discrimination and loss of status occurs
5.
Power differences
Link & Phelan, 2001
Source: Puhl, R.M.
(2013) Clinical
Implications of Obesity.
Presentation, Rudd
Center for Food Policy
19
and Obesity.
OBESITY STIGMA : A WIDESPREAD PROBLEM
 Research shows overt weight-based discrimination has increased among children
and adults
 Children report weight as most common reason for bullying
 One study showed that 92.5% of undergraduate sample endorsed fat stigma
 Family members followed by physicians are most common source of weight
stigmatization
Ambwani et al, 2014; Andreyeva, et al., 2008. Puhl &Brownell, 2006; Puhl et al., 2011
WEIGHT STIGMA IN EMPLOYMENT
 People with a higher BMI are…
 Less likely to be interviewed
 Less likely to be hired
 Earn less
 Fewer promotions
Employers rate larger people as


Less competent, lazy, sloppy, disagreeable, emotionally unstable
Puhl & Peterson, 2014
WEIGHT STIGMA IN EDUCATION
 Children with a higher BMI perform poorer academically
 Research shows weight-based teasing may play a mediating role
 Children report missing school due to weight-based victimization
 Teachers have lower expectations of children with a high BMI
 Larger sized children are characterized by teachers as:
 Untidy
 Emotional
 Less likely to succeed at work
 More like to have family problems
Krukowski, et al., 2009; Neumark-Sztainer, Story, & Harris, 1999; Puhl, Luedicke, & Heuer, 2011
WEIGHT BIAS IN HEALTH CARE
WEIGHT BIAS IS PREVALENT ACROSS PROFESSIONAL GROUPS
 Studies documented weight bias in:
 Physicians
 Nurses
 Medical students
 Psychologists
 Dietitians
 Fitness professionals
Puhl & Brownell, 2001; Puhl & Heuer, 2009
PERCEPTIONS OF CLIENTS WITH OBESITY
 Providers view obese patients as
 Non compliant
 Lazy
 Awkward
 Weak-willed
 Dishonest
 Unsuccessful
 Unintelligent
Ferrante et al., 2009; Campbell et al., 2000; Fogelman et al., 2002; Foster, 2003; Hebl & Xu, 2001; Puhl & Heuer, 2009; Huizinga et al., 2010
WEIGHT BIAS
 Physicians report
 As patient BMI increases, physicians report:
 having less patience
 less desire to help the patient
 seeing obese patients was a waste of their time
 having less respect for patients
Hebl & Xu, 2001; Huizinga et al., 2009
WEIGHT BIAS
 Nurses report:
 31% “would prefer not to care for obese patients”
 12% “would prefer not to touch obese patients”
 24% agreed that obese patients “repulsed them”
Poon & Tarrant, 2009; Brown, 2006; Bagley, 1989; Hoppe & Ogden, 1997; Maroney & Golub, 1992
PATIENT REACTIONS
 Feel berated & disrespected by providers
 Report that their weight is blamed for all problems
 Upset by comments about their weight from doctors
 Reluctant to address weight concerns
 Perceive that they will not be taken seriously
Anderson & Wadden, 2004; Bertakis & Azari, 2005; Brown et al., 2006; Edmunds, 2005
IS CARE AFFECTED?
 Provider interactions with obese patients
 Less time spent in appointments
 Less discussion with patients
 More assignment of negative symptoms
 Less intervention
Bacquier et al., 2005; Bertakis & Azari, 2005; Campbell et al., 2000; Galuska et al., 1999; Hebl & Xu, 2001; Kristeller & Hoerr, 1997
IMPACT ON CARE
 Patients with obesity are less likely to obtain…
 Preventive health services & exams
 Cancer screens, pelvic exams, mammograms
 and are more likely to…
 Cancel appointments
 Delay appointments and preventive care service
Adams et al., 1993; Aldrich & Hackley, 2010; Drury & Louis, 2002; Fontaine et al., 1998; Olson et al., 1994, Ostbye et al., 2005; Wee et al., 2000
AVOIDANCE OF CARE
 Study of 498 women:
 Obese women delayed preventive services despite high access
 Women attributed their decisions to:

Disrespect from providers
 Embarrassment of being weighed
 Negative provider attitudes
 Medical equipment too small
*Barriers increased with BMI
Amy et al. (2006)
HOW STIGMA “GETS UNDER THE SKIN”
WHAT ARE THE HEALTH CONSEQUENCES OF ALL THIS?
32
ALLOSTATIC LOAD
 Multi-disciplinary, framework for studying the relationship between stress and disease
 Operationalized as a index of physiological dysregulation involving multiple organ
systems
 Captures how our body copes with threatening or unpredictable environmental
stimuli
 Is the consequence of regulatory “wear and tear” on the body and brain that leads to
illness
33
McEwen, B. S., & Stellar, E. (1993).
ALLOSTATIC LOAD
 Chemical messengers released in
brain in response to stress
 Chronic or frequent demands for
these messengers can lead to
insufficient, non-habituating, or
prolonged production
 Metabolic, inflammatory, and
cardiovascular systems all become
dysregulated
35
Beckie, (2012)
PERCEIVED DISCRIMINATION AND HEALTH
 2009 Meta-analysis shows very robust associations
 Data from 110 studies examining mental health

Symptoms of depression, anxiety, PTSD, psychosis, paranoia, psychological distress, general wellbeing, life satisfaction, self-esteem, perceived stress, anger, etc.)
 Data from 36 studies examining physical health
 Outcomes included BP, plaque, heart rate variability, CVD, pelvic inflammatory disease, yeast
infections, respiratory conditions, etc.
36
Pascoe & Smart Richman, (2009)
WEIGHT STIGMA AND MENTAL HEALTH
 Depression
 Anxiety
 Disordered eating
 Self-esteem
 Exercise Avoidance
37
Durso et al., (2012); Greenleaf, Petrie, & Martin, (2014); Hilbert, Braehler, Haeuser, & Zenger,(2014)
WEIGHT/PHYSICAL APPEARANCE DISCRIMINATION AND
AMBULATORY BP
 Sample of 207 Black and White adolescents
 Rating physical appearance/weight as being the primary reason for being
discriminated against was a predictor of higher ambulatory blood pressure after
controlling for BMI, race, sex, physical activity
 Race was also a predictor of BP
Matthews, Salomon, Kenyon, & Zhou (2005)
38
PERCEIVED WEIGHT STIGMA AND HPA ACTIVATION
 Weight stigma frequency and stress hormones measured in 45
women with high BMI
 Models controlled for abdominal adiposity, perceived stress, age,
income, education
 Significant associations between weight stigma and stress
hormones regardless of weight status
39
Tomiyama, Epel, McClatchey, et al. (2014)
OBESITY STIGMA AND HEALTH BEHAVIOR
HEALTH CONSEQUENCES
 Maladaptive eating behaviors
 Binge eating, unhealthy weight control practices, comping with stigma my eating more food
 Study: Survey of 2,449 women
 How do they cope with stigma experiences?

79% reported eating; turning to food as coping mechanism

Haines, et al., 2006; Neumark-Sztainer et al., 2002; Puhl & Brownell, 2006, Puhl et al., 2007; Puhl & Luedicke, 2011
HEALTH CONSEQUENCES
 Internalizing Weight Stigma
 Study: 1013 women
 (national non-profit weight loss support organization)
 Women who internalized experiences of weight stigma and blamed themselves engaged in more
frequent binge eating
 (even after accounting for self-esteem, depression, and amount of stigma experienced)
Puhl, Moss-Racusin, Schwartz, (2007)
BEHAVIORAL CONSEQUENCES OF OBESITY STIGMA
 Higher calorie intake
 Higher program attrition
 Less weight loss
 Avoidance of physical activity
 Lower motivation for exercise
Bauer et al., 2004; Faith et al, 2002; Matthews et al., 2005; Schwimmer et al., 2003, Storch et al., 2006; Schmaltz, 2010; Seacat & Mickelson 2009; Vartanian &
Shaprow, 2008; Vartanian & Novak, 2011
IN SUM…DOES A HIGH BMI OR THE STRESS OF BEING STIGMATIZED
FOR IT CAUSE DISEASE?
Source: Puhl & Heuer, (2010)
OBESITY STIGMA IN PREGNANCY
UPSTREAM AND DOWNSTREAM DETERMINANT OF POOR BIRTH OUTCOMES?
Root Causes
Social
Determinants
STUDIES OF WEIGHT STIGMA AND PREGNANCY
 Little research conducted on chronic or recent obesity stigma experienced by
pregnant women with a high BMI
 Given the rates of obesity stigma and associated pregnancy complications in the U.S.
it is critical to examine this issue
DeJoy & Bittner (2015)
“SIZE-ISM” AS STRUCTURAL DISADVANTAGE/DOWNSTREAM
INFLUENCE
 Intersection of weight and gender discrimination is major source of inequity in the
US. (Mason, 2012).
 Overweight and obese individuals are at increased risk of employer discrimination.
(Puhl & Heuer, 2011; Puhl, Heuer, & Brownell, 2010)
 Obese women tend to have lower levels of educational attainment and income and a
lower marriage rate than their thinner peers. (Puhl & Heuer, 2010)
INTERNATIONAL STUDIES OF WEIGHT STIGMA AND PREGNANCY
 From Scandinavia, Australia and the UK
 Depersonalization
 Medicalization
 Lack of respect
Smith & Lavender(2011)
U.S. STUDY ON EXPERIENCES OF WEIGHT STIGMA IN MATERNITY
CARE
DeJoy, Bittner, & Mandel (2015).
SELECTED QUOTES
 I basically got a lecture every time I went in. They made judgments about what I
ate, about how much I exercised. They never asked me; they just said things like
“don’t drink soda,” which I don’t, and “don’t eat candy bars,” which I don’t.
 They kept saying the baby was going to be super large and you’ll never be able to
deliver vaginally because he’ll be so big – and he wasn’t; he was a perfectly normal
7lbs, 6oz.
 I had one doctor who came to see me in the hospital …I was eating a small
snack-size bag of cookies and he walked in and just totally scoffed at me that I was
eating cookies. He said, “It’s things like that, I have to tell you… I can’t even
prescribe you birth control, because you’re too fat for birth control pills.”
 I was not pre-eclamptic, I wasn’t diabetic, I wasn’t having any additional problems, I
had no complications. I was just “fat while pregnant” and therefore needed a csection.
WEIGHT STIGMA: A SOURCE OF UNNECESSARY INTERVENTIONS?
 Higher risk of cesarean delivery attributable to labor management, not BMI. (Abenhaim &
Benjamin, 2011)
OBESITY STIGMA AS A SOCIAL DETERMINANT OF DISPARITIES IN
BIRTH OUTCOMES
Social
Disadvantage
Internalization
Poor Quality of
Care
Stress
Avoidance of
Care
Pathophysiology
Health Behaviors
Inappropriate
Interventions
Poor Birth
Outcomes
Poor Birth
Outcomes
RESEARCH QUESTIONS/GAPS IN THE LITERATURE
 How do women with obesity experience stigma over the lifecourse?
 Does pregnancy exacerbate or alleviate stigma?
 Is stigma associated with poorer mental health during pregnancy?
 If so, what coping behaviors are used and are they healthful or not?
 Does stress manifest in biological markers in pregnancy?
 Do women who experience more stigma or more distress due to stigma have poorer birth outcomes?
 How does the experience of stigma vary by race/ethnicity and other sociodemographic
variables?
 How much of the variation in the medicalization of obesity in pregnancy can be explained by
physiology versus provider bias?
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