Mechanisms underlying weight status and healthcare avoidance in women: A study of weight stigma, body-related shame and guilt, and healthcare stress

Obesity and responsibility: Is it time to rethink agency?

Despite obesity declared a disease, there still exists considerable weight stigma in both popular culture and health care, which negatively impacts policy making regarding prevention and treatment. While viewed as a choice or a failure of willpower by many, evidence exists to challenge the argument that both weight gain and failure to achieve weight loss maintenance are the individuals' fault due to personal failure or lack of responsibility. In this article, we draw upon literature from obesity treatment, neuroscience, philosophy of mind, and weight stigma to challenge the commonly held beliefs that individuals are free to choose how much they can weigh, and achievement of long-term weight loss maintenance is completely subject to conscious choice. In reality, the regulation of hunger, satiety, energy balance, and body weight takes place in subcortical regions of the brain. Thus, hunger and satiety signals are generated in regions of the brain, which are not associated with conscious experience. This points towards biological determinism of weight and challenges ideas of willpower and resultant moralization regarding body weight regulation. In this article, we will thus argue that in the context of dysregulation of hunger and satiety contributing to the obesity epidemic, a wider discourse related to personal responsibility and the stigma of obesity is needed to enhance understanding, prevention, and treatment of this complex disease. Obesity is a chronic disease requiring personalized treatment. Lifestyle interventions alone may not be enough to achieve medically significant and sustained weight loss for many individuals with obesity. By understanding that obesity is not due to a lack of motivation or willpower, the availability and utilization of additional treatments or combination of treatments such as lifestyle, pharmacotherapy, and surgery are likely to improve the quality of life for many suffering with this disease.

Two-year follow-up cohort study focused on gender-specific associations between socioeconomic status and body weight changes in overweight and obese middle-aged and older adults

OBJECTIVE

As overall spread of obesity in populations is generally acknowledged to result from unhealthy lifestyles rather than individual genetic makeup, this study aimed to gain specific insights into its determinants through assessing the prevalent associations between individual socioeconomic status (SES) and weight loss in overweight and obese men and women.

METHODS

A prospective, 2-year follow-up study covered 3362 (38.0% men) respondents, aged 43-64 years, body mass index ≥25 kg/m2. Changes in body weight were estimated as a percentage of initial weight. Three categories of changes were defined: gained ≥3%, stable (gained <3% or lost <3%), lost ≥3%. Body weight loss was determined against three categories: lost ≥3 to <5%, lost ≥5 to <10%, lost ≥10%. Select SES variables (ie, gender, age, education, marital status, occupational activity and income) were determined in line with the Health Status Questionnaire. The associations between SES and body weight changes were analysed with the aid of logistic regression models. The results were presented as ORs with 95% CIs.

RESULTS

Only 18% of the respondents had complied with the medical recommendations on weight loss. Significant differences were encountered between the gender, age and occupational activity variables and the weight loss one. Multifactorial models were used to determine the following gender-specific associations between SES and weight loss. Men with moderate income had significantly higher odds for weight loss (≈75%), as compared with the higher earners, whereas women with low income, occupationally inactive, had significantly higher odds (≈30% and ≈50%, respectively), as compared with the high earners and occupationally active ones.

CONCLUSIONS

Lower education, male gender, lower income per household, older age and unemployment status were the established factors predisposing to obesity. While aiming to ensure effectiveness of the measures specifically aimed at preventing obesity, population groups deemed most at risk of potential weight gain must prior be identified.

Focus on the Beauty of Body: The Mediation Role of Body Appreciation Between Perfectionism and Body-Related Shame and Body-Related Guilt

Objectives: According to traditional views, perfectionists are prone to experience shame and guilt. As a relative part of negative body image, body appreciation reflects an appreciation attitude toward physical characteristics, functionality, and health, accepting and appreciating all parts and functions of the body, predicting body-related shame and guilt. Methods: Therefore, body appreciation was examined for its potential mediating role in the relationship between two dimensions of perfectionism (e.g., healthy perfectionism and unhealthy perfectionism) and body-related shame and body-related guilt among 514 females. Results: The results highlight that body appreciation partially mediated the relationship between perfectionism and body-related shame and body-related guilt. Implications for enhancing body appreciation among females between experiencing healthy or unhealthy perfectionism and body-related shame and body-related guilt feelings are discussed. Conclusions: These findings underscore the importance of considering body appreciation in addressing perfectionism dimensions and body-related shame and body-related guilt. Research and clinical implications are also addressed.

Internalized weight stigma and the relationship between weight perception and negative body-related self-conscious emotions

Individuals who perceive themselves as "overweight" experience higher negative body-related self-conscious emotions than those who do not. Theoretical and empirical evidence suggests internalized weight stigma may be an important mediator of the relationship between weight perception and self-conscious emotions. Overcoming common measurement limitations and sampling limitations, the present study investigated whether gender moderates the associations among weight perceptions, internalized weight stigma, and negative body-related self-conscious emotions in 104 young adults (64 % women). Individuals who perceived themselves as too heavy (52 %) experienced higher body-related shame and guilt compared to those who perceived themselves as about right. Internalized weight stigma mediated these associations in women but not men, such that perceiving oneself as too heavy was associated with higher internalized weight stigma, which was associated with higher body-related shame and guilt in women. Results underscore the importance of internalized weight stigma as a potential target for intervention among women of diverse weight statuses who are prone to experiencing body-related shame and guilt.

Weight Bias During the COVID-19 Pandemic

PURPOSE OF REVIEW

This review explores potential sources of weight bias and stigma during the COVID-19 pandemic, including "quarantine-15" messages and discussion of obesity in media and public health campaigns. We examine evidence of the effects of weight bias on well-being during the pandemic and highlight unanswered questions to be addressed in future research.

RECENT FINDINGS

Studies that have investigated weight change during stay-at-home orders have yielded mixed findings and relied predominantly on self-reported retrospective recall, thus providing weak evidence of a widespread "quarantine-15" effect. No studies to date have evaluated the effects on weight stigma and health of obesity-focused COVID-19 media and public health messages. Individuals with a history of experiencing weight bias may be more vulnerable to binge eating and psychological distress during the pandemic. Weight bias and stigma during the COVID-19 pandemic, and their effects on health and well-being, warrant greater investigation and consideration in public health efforts.

Evaluating the impact of a brief Health at Every Size®-informed health promotion activity on body positivity and internalized weight-based oppression

Weight-based oppression, including negative attitudes about body weight, and harassment, stigma, and discrimination based on body weight, is a widespread phenomenon that leads to considerable distress and poor health and wellbeing outcomes. Conversely, body positivity is a multi-faceted concept that encompasses body acceptance, body appreciation, and body love, and adaptive approaches protective of health and wellbeing. The aim of this study was to evaluate the impact of a brief health promotion activity informed by Health at Every Size® and critical health promotion principles on body positivity and internalized weight-based oppression in female students at Qatar University. A quasi-experimental mixed methods pre-post evaluation design was used, with quantitative assessment of body positivity and internalized weight-based oppression before the activity, immediately afterwards, and 10 weeks later, and qualitative assessment at the 10-week follow up. Measures used were the Body Appreciation Scale 2, Modified Weight Bias Internalization Scale, Fat Attitudes Assessment Toolkit Size Acceptance and Self Reflection on Body Acceptance subscales, and an open-ended questionnaire. Body acceptance and appreciation increased significantly after the activity. Qualitative results suggest that these improvements were sustained at follow up. Brief Health at Every Size® informed health promotion activities show potential to improve health and wellbeing.

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.

Reliability of Markers for Breast Hypoplasia in the Early Postpartum Period

BACKGROUND

Breast hypoplasia is one reason for insufficient milk supply. Case reports use wide intra-mammary width and certain breast appearances as markers of breast hypoplasia. However, the reliability of these variables has not been determined.

RESEARCH AIMS

To test the (i) interrater and intrarater reliability of intra-mammary width measurement and interrater reliability of categorizing women's breasts into breast types, and (ii) feasibility and acceptability of study procedures for the participants.

METHODS

This was a prospective, longitudinal, non-experimental design with survey and observational components of a convenience sample of early postpartum women (N = 31). Interrater and intrarater reliability were measured using intraclass correlation coefficient for agreement for intra-mammary width measurements. Interrater reliability was measured using weighted kappa for agreement for categorizing breast type. Feasibility and acceptability of study procedures were collected 1 month later.

RESULTS

Excellent intrarater and interrater reliability for the intra-mammary width measurement (ICC = 0.99, 95% CI [0.99, 0.997] and ICC = 0.88, 95% CI [0.74, 0.94], respectively) and fair interrater reliability for breast type categorization (k = 0.35, 95% CI [-0.05, 0.75]) with high level of agreement between raters (97%) were achieved. Proportions of participants agreeing to breast photography and acceptability of study procedures were 68% (21/31) and 100% (28/28) respectively.

CONCLUSION

The excellent reliability for the intra-mammary width measurement means it provides a useful measure for future research. Since the "fair" reliability of categorizing breast type was due to lack of breast shape range in our sample, future research could assess the breasts of women with different medical profiles.

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.

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

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

Prenatal care experiences among pregnant women with obesity in Wisconsin, United States: a qualitative quality improvement assessment

BACKGROUND

Stigma and bias experienced during prenatal care can affect quality of care and, ultimately, the health of pregnant women with obesity and their infants. We sought to 1) better understand the bias and stigma that women with BMIs ≥40 kg/m2 experience while receiving prenatal care, 2) gauge women's interest in group prenatal education for women with obesity, and 3) gather feedback about their preferred weight-related terminology.

METHODS

We conducted and thematically content-analyzed 30 semi-structured interviews of women with BMIs ≥40 kg/m2 who received prenatal care at a university-affiliated teaching hospital in the Midwest region of the United States.

RESULTS

All women recalled positive experiences during their perinatal care during which they felt listened to and respected by providers. However, many also described a fear of weight-related bias or recalled weight-based discrimination. Women reacted favorably to a proposed group prenatal care option for pregnant women with obesity that focused on nutrition, physical activity, and weight management. Women rated "weight" and "BMI" as the most desirable terms for describing weight, while "large size" and "obesity" were rated least desirable.

CONCLUSIONS

Many pregnant women with BMIs ≥40 kg/m2 experience bias in the prenatal care setting. Potential steps to mitigate bias towards weight include improving provider awareness of the experiences and perspectives of this population, expanding prenatal care options targeted towards women with high BMIs, including group care, and using patient-preferred weight-related terminology. Through the remainder of this manuscript, wherever possible, the term "high BMI" will be used in place of the term "obesity" to describe women with BMI ≥ 30 kg/m2 in order to respect the preferred terminology of the women we interviewed.

"Fat broken arm syndrome": Negotiating risk, stigma, and weight bias in LGBTQ healthcare

In the U.S., the weight of LGBTQ people-and sexual minority women in particular-is a key focus for those addressing sexual and gender minority health disparities. Sociomedical stigma related to both fat and sexuality, however, complicates patient-provider perceptions and discussions about weight and health. I analyzed data from interviews with LGBTQ patients, healthcare employees, and observations at a LGBTQ healthcare organization to reveal how weight bias becomes a barrier to care for LBQ cisgender women, transgender men, and nonbinary people assigned female. Understood by patients as similar to "trans broken arm syndrome,"-wherein providers attribute health concerns of trans people to minority gender identities and gender affirming care-patients report "fat broken arm syndrome," wherein providers are perceived to attribute patient health concerns to weight. Patients interpret weight bias as intersectional stigma-related to multiple marginalized identities and embodiments-that puts their health at risk. Healthcare professionals make sense of risk, however, through competing fat frames. Although patient narratives suggest the promise of utilizing stigma-reduction approaches, many providers-typically those who do not share patient standpoints-emphasize the importance of framing fat as an urgent health risk in order to "do no harm." This case advances knowledge by demonstrating the relational process through which interventions designed to ameliorate health disparities may inadvertently discourage marginalized, "at-risk" patients from healthcare access and adherence.

Patient Recommendations for Providers to Avoid Stigmatizing Weight in Rural-Based Women With Low Income

Purpose

Weight stigma has become widespread within health care and disproportionately affects women, who are under greater appearance-based scrutiny than men. It is also well established that rural-based individuals with low incomes suffer greater health disparities compared with urban, higher-income counterparts, yet studies examining recommendations for nonstigmatizing health care among higher-weight women from low-income rural settings are lacking. This study examined the experiences and recommendations of higher-weight, low-income, rural women, with the aim of improving health care for similar populations.

Methods

In-depth, semi-structured interviews were conducted in a rural region of the Midwestern United States to explore participants' recommendations for redressing stigma within health care. All participants (n=25) self-identified as higher-weight, low-income, rural women.

Results

All participants experienced or were aware of weight stigma within health care. Themes identified from responses were understanding patients and their situations, offering options and supplemental information, communicating effectively, taking time, and having a positive attitude. Patient recommendations focused on correcting physician biases, rapport-building, and providing holistic care.

Conclusions

The findings suggest that weight stigma is prevalent within health care provided to low-income women in rural U.S. Midwest and that there are specific communication and training approaches that may reduce the prevalence of weight stigma in health care.

Patients' experiences of the caring encounter in health promotion practice: a qualitative study in Swedish primary health care

BACKGROUND

Previous studies have reported that organizational structures and cultures in primary health care are obstacles to district nurses doing successful work in health promotion practice (HPP). Because organizational structures are not easily changed, Jean Watson's Attending Nurse Caring Model (ANCM) was introduced and piloted at a primary health care center in Sweden, aiming to transform HPP so as to empower district nurses and increase their work satisfaction.

AIM

To investigate patients' experiences of the caring encounter in HPP after introduction of the ANCM in Swedish primary health care, the aim being to explore the essential components of the caring encounter between patients and district nurses.

METHODS

A descriptive and qualitative research design was used. Data collection was performed using individual face-to-face interviews with twelve patients at risk for developing CVD. Data analysis consisted of both deductive content analysis, using a categorization matrix based on the ANCM and, subsequently, inductive latent content analysis.

RESULTS

The findings were abstracted into three themes: 1.'Feeling the deepest essence of being cared for': to be respected and being put at the center of the encounter; 2. 'Feeling acceptance and worth': being treated with openness and permissive attitudes, 3. 'Being in a supportive atmosphere that promotes hope': to feel trust and being trusted in the encounter, and being empowered by hope. The unifying main theme of the caring encounter was abstracted as 'Experiencing human dignity'.

CONCLUSION

The present study revealed that the essence of the caring encounter between patients and district nurses in HPP is to be unconditionally accepted in an environment that inspires hope and encouragement. The ANCM seems to be a promising model to use for strengthening the caring encounter and supporting CVD patients in making healthy lifestyle choices. However, further studies of qualitative and quantitative designs are needed to investigate what the ANCM can contribute to HPP in Swedish primary health care.

Military transgender care

Transgender individuals have a long-standing history of honorable service in the United States Military. However, politics have had an impact on their ability to openly serve in uniform as policies continually change rapidly with each new administration. This article describes the shifting political landscape of policies related to whether (or not) transgender individuals can serve in the military, and how this has affected the health care experiences of transgender individuals and the ability for nurse practitioners to provide quality health care to the transgender population serving on active duty.

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.

Prevention of noncommunicable diseases by interventions in the preconception period: A FIGO position paper for action by healthcare practitioners

With the increase in obesity prevalence among women of reproductive age globally, the risks of type 2 diabetes, gestational diabetes, pre-eclampsia, and other conditions are rising, with detrimental effects on maternal and newborn health. The period before pregnancy is increasingly recognized as crucial for addressing weight management and reducing malnutrition (both under- and overnutrition) in both parents to reduce the risk of noncommunicable diseases (NCDs) in the mother as well as the passage of risk to her offspring. Healthcare practitioners, including obstetricians, gynecologists, midwives, and general practitioners, have an important role to play in supporting women in planning a pregnancy and achieving healthy nutrition and weight before pregnancy. In this position paper, the FIGO Pregnancy Obesity and Nutrition Initiative provides an overview of the evidence for preconception clinical guidelines to reduce the risk of NCDs in mothers and their offspring. It encourages healthcare practitioners to initiate a dialogue on women's health, nutrition, and weight management before conception. While acknowledging the fundamental importance of the wider social and environmental determinants of health, this paper focuses on a simple set of recommendations for clinical practice that can be used even in short consultations. The recommendations can be contextualized based on local cultural and dietary practices as part of a system-wide public health approach to influence the wider determinants as well as individual factors influencing preconception health.

Guideline No. 392-Pregnancy and Maternal Obesity Part 2: Team Planning for Delivery and Postpartum Care

OBJECTIVE

This guideline will review key aspects in the pregnancy care of women with obesity. Part I will focus on Preconception and Pregnancy Care. Part II will focus on Team Planning for Delivery and Postpartum Care.

INTENDED USERS

All health care providers (obstetricians, family doctors, midwives, nurses, anaesthesiologists) who provide pregnancy-related care to women with obesity.

TARGET POPULATION

Women with obesity who are pregnant or planning pregnancies.

EVIDENCE

Literature was retrieved through searches of Statistics Canada, Medline, and The Cochrane Library on the impact of obesity in pregnancy on antepartum and intrapartum care, maternal morbidity and mortality, obstetric anaesthesia, and perinatal morbidity and mortality. Results were restricted to systematic reviews, randomized controlled trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to September 2018. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

VALIDATION METHODS

The content and recommendations were drafted and agreed upon by the authors. Then the Maternal-Fetal Medicine Committees peer reviewed the content and submitted comments for consideration, and the Board of the Society of Obstetricians and Gynaecologists of Canada (SOGC) approved the final draft for publication. Areas of disagreement were discussed during meetings at which time consensus was reached. The level of evidence and quality of the recommendation made were described using the Evaluation of Evidence criteria of the Canadian Task Force on Preventive Health Care.

BENEFITS, HARMS, AND COSTS

Implementation of the recommendations in these guidelines may increase obstetrical provider recognition of the issues affecting pregnant individuals with obesity, including clinical prevention strategies, communication between the health care team, the patient and family as well as equipment and human resource planning. It is hoped that regional, provincial and federal agencies will assist in the education and support of coordinated care for pregnant individuals with obesity.

GUIDELINE UPDATE

SOGC guideline will be automatically reviewed 5 years after publication. However, authors can propose another review date if they feel that 5 years is too short/long based on their expert knowledge of the subject matter.

SPONSORS

This guideline was developed with resources funded by the SOGC.

SUMMARY STATEMENTS

RECOMMENDATIONS.

Experiences of weight stigma in everyday life: An ecological momentary assessment study

Weight stigma and discrimination have been linked to negative health outcomes. Most research on this topic is retrospective, which may not accurately capture day-to-day experiences. The current used ecological momentary assessment to examine weight stigma and discrimination in everyday life. Participants answered ecological momentary assessments about the nature, frequency, and contextual details of weight stigma and discrimination. Over the course of the study, only eight episodes of weight stigma and discrimination were reported. Given that prior ecological momentary assessment studies reported substantially more frequent weight stigma and discrimination, possible explanations for the findings and implications for future research are discussed.

What words should we use to talk about weight? A systematic review of quantitative and qualitative studies examining preferences for weight-related terminology

Evidence of weight stigma and its harmful consequences have led to increased attention to the words that are used to talk about obesity and body weight, including calls for efforts to carefully consider weight-related terminology and promote respectful language in the obesity and medical fields. Despite increased research studies examining people's preferences for specific words that describe body weight, there has been no systematic review to synthesize existing evidence on perceptions of and preferences for weight-related terminology. To address this gap, the current systematic review identified 33 studies (23 quantitative, 10 qualitative) that examined people's preferences for weight-related terminology in the current research literature (from 1999 to 2019). Across studies, findings generally suggest that neutral terminology (eg, "weight" or "unhealthy weight") is preferred and that words like "obese" and "fat" are least acceptable, particularly in provider-patient conversations about weight. However, individual variation in language preferences is evident across demographic characteristics like race/ethnicity, gender, and weight status. Of priority is future research that can improve upon the limited diversity of the existing literature, both with respect to sample diversity and the use of culturally relevant weight-related terminology, which is currently lacking in measurement. Implications for patient-provider communication and public health communication are discussed.

Does body shame mediate the relationship between parental bonding, self-esteem, maladaptive perfectionism, body mass index and eating disorders? A structural equation model

PURPOSE

Body shame has been strongly associated with eating pathology. However, less is known about the predisposing factors linked to these feelings and how they interact with other variables in eating disorder development. Thus, the aim of the present study was to provide a preliminary understanding of the relationship between body shame and some of the major risk factors for eating disorder onset, identifying the possible mechanisms of action. Specifically, we tested a structural equation model in which perceived parental bonding, self-esteem, perfectionism, and body mass index are associated with eating disorder risk via body shame.

METHODS

1156 high school students aged 13-20 were screened by means of self-report measures of parental behavior, self-esteem, perfectionism, body shame and eating disorder risk. The height and weight of each individual were measured.

RESULTS

In predicting eating disorder risk, parental protectiveness (β = 0.09), body mass index (β = 0.18), self-esteem (β = - 0.14) and body shame (β = 0.58) had a direct effect on this variable and overall our model accounted for 58% of its variance. The experience of shame related to one's body appeared to have a considerably significant influence on eating disturbances vulnerability and it also serves as a mediator between other risk factors and eating disturbance risk. A series of multi-group analyses indicated no significant difference between males and females.

CONCLUSION

The emotion of shame may enhance our understanding of eating disorders, as well as being a salient factor for the development of preventive programs and treatment approaches.

LEVEL OF EVIDENCE

Level V, cross-sectional descriptive study.

The Happy American Body 2.0: Predictors of affective body satisfaction in two U.S. national internet panel surveys

The first national study of body image was reported four decades ago in the article The Happy American Body (Berscheid et al., 1973). To provide a modern follow-up to this study, we used two Internet panel surveys of U.S. adults to examine feelings about appearance (Survey 1: Married N = 1095; Single N = 5481) and weight, appearance, body, and muscle size/tone (Survey 2: N = 1601). Mean ages across samples for men and women ranged from 42-53. On the positive side, many men and women were somewhat-to-very satisfied with their appearance (67 %; 57 %), overall body (61 %; 46 %), weight (54 %; 42 %), and muscle tone/size (56 %; 41 %). Mean gender differences were small (Cohen's ds = 0.18-0.32), as were sexual orientation differences within each gender (ds = |0.00-0.25|). Looking at negative body image, fewer men than women were somewhat-to-very unhappy with their appearance among married (19 %; 29 %) and single participants (29 %; 35 %), and fewer men were somewhat-to-extremely dissatisfied with their appearance (18 %; 24 %), body (27 %; 39 %), weight (36 %; 49 %), muscle tone/size (27 %; 41 %). Nearly one-fifth of men (18 %) and one-fourth of women (27 %) were very-to-extremely dissatisfied with at least one of these traits, highlighting the importance of body image interventions.

The Effect of a Food Addiction Explanation Model for Weight Control and Obesity on Weight Stigma

There is increasing scientific and public support for the notion that some foods may be addictive, and that poor weight control and obesity may, for some people, stem from having a food addiction. However, it remains unclear how a food addiction model (FAM) explanation for obesity and weight control will affect weight stigma. In two experiments (N = 530 and N = 690), we tested the effect of a food addiction explanation for obesity and weight control on weight stigma. In Experiment 1, participants who received a FAM explanation for weight control and obesity reported lower weight stigma scores (e.g., less dislike of ‘fat people’, and lower personal willpower blame) than those receiving an explanation emphasizing diet and exercise (F_(4,525) = 7.675, p = 0.006; and F_(4,525) = 5.393, p = 0.021, respectively). In Experiment 2, there was a significant group difference for the dislike of ‘fat people’ stigma measure (F_(5,684) = 5.157, p = 0.006), but not for personal willpower weight stigma (F_(5,684) = 0.217, p = 0.81). Participants receiving the diet and exercise explanation had greater dislike of ‘fat people’ than those in the FAM explanation and control group (p values < 0.05), with no difference between the FAM and control groups (p > 0.05). The FAM explanation for weight control and obesity did not increase weight stigma and resulted in lower stigma than the diet and exercise explanation that attributes obesity to personal control. The results highlight the importance of health messaging about the causes of obesity and the need for communications that do not exacerbate weight stigma.

Impacto das Consequências Psicossociais do Estigma do Peso no Tratamento da Obesidade: uma Revisão Integrativa da Literatura

Resumo Trata-se de uma revisão integrativa da literatura, cujo objetivo foi investigar as consequências psicossociais do estigma do peso em adultos e sua influência no tratamento da obesidade. A busca envolveu as bases de dados PubMed, Web of Science e PsycINFO e incluiu artigos em inglês e português publicados nos últimos cinco anos. Foram selecionados quinze artigos, analisados a partir da definição de dois subtemas: “A relação entre estigma, psicopatologias e transtornos do comportamento alimentar” e “A estigmatização entre os profissionais de saúde”. Os resultados apontam para o grande impacto do estigma do peso na saúde psicossocial da pessoa com obesidade e para as atitudes estigmatizantes dos profissionais de saúde no cuidado terapêutico. Observa-se um enfoque patológico do enfrentamento da obesidade com estratégias de cunho comportamental que minimizam a compreensão da problemática. Atualmente, o tratamento da obesidade promovido pelo modelo biomédico não abrange as demandas de caráter psicossocial, o que torna necessário a educação permanente para capacitação dos profissionais de saúde e a implementação de protocolos de intervenção específicos a este grupo populacional. A contribuição de profissionais de diversas áreas, e em especial, daqueles de saúde mental, é essencial em atenção às diferentes particularidades do tratamento, devendo ser baseada em uma perspectiva integral e humanizada, e inserida nos diferentes contextos psicossociais. Devido à perversidade do estigma do peso e suas graves consequências, futuros estudos são necessários para investigação desse problema e das atitudes dos profissionais da saúde, familiares, mídia e da população em geral em relação à pessoa com obesidade.

Development and testing of a model for risk and protective factors for eating disorders and higher weight among emerging adults: A study protocol

Research has demonstrated that eating disorders (ED) and higher weight have lifetime co-occurrence suggesting that they may be best considered within a common etiological model. Although we know that body dissatisfaction is likely to be a risk factor for both outcomes, other proposed risk and protective factors for each condition have not been adequately explored. The current paper tests a conceptual model that is based on a review of the existing literature from both areas of scholarship. It considers biological, sociocultural, psychological, and behavioral factors that may contribute to both outcomes. The model will be tested in a longitudinal design with an initial sample of 600 emerging adults (aged 18-30) per country in nine different countries (total sample = 5400 participants). Questionnaires will be completed online on two occasions, 12 months apart. The first full phase of the study commenced in July 2018, the same time Body Image was approached to publish this protocol paper (the final revised paper was submitted in September 2019), and data collection will be finalized in December 2019. Multi-group path analysis will identify the biopsychosocial predictors - both cross-sectionally and longitudinally - of both ED and higher weight, and how these vary across countries and gender.

Directive clinique No 392 - Grossesse et obésité maternelle Partie 2 : Planification en équipe de l'accouchement et soins post-partum

OBJECTIF

La présente directive clinique aborde les aspects essentiels des soins prénataux chez les femmes atteintes d'obésité. La partie 1 porte sur la préconception et les soins prénataux. La partie 2 porte sur la planification en équipe de l'accouchement et les soins post-partum. UTILISATEURS CONCERNéS: Tous les fournisseurs de soins de santé (obstétriciens, médecins de famille, sages-femmes, infirmières, anesthésiologistes) qui prodiguent des soins relatifs à la grossesse auprès de femmes atteintes d'obésité.

POPULATION CIBLE

Femmes atteintes d'obésité qui sont enceintes ou prévoient le devenir. DONNéES PROBANTES: Des recherches ont été menées en consultant les ressources de Statistique Canada, de Medline et de Cochrane Library en vue d'en tirer la littérature relativement aux effets de l'obésité durant la grossesse sur les soins prénataux et intrapartum, la morbidité et la mortalité maternelles, l'anesthésie obstétricale ainsi que sur la morbidité et la mortalité périnatales. Seuls les résultats de revues systématiques, d'essais cliniques randomisés ou comparatifs et d'études observationnelles ont été retenus. Aucune restriction de date ou de langue n'a été employée. Les recherches ont été mises à jour régulièrement, et les résultats ont été incorporés à la directive clinique jusqu'en septembre 2018. Nous avons également tenu compte de la littérature grise (non publiée) obtenue sur les sites Web d'organismes d'évaluation des technologies de la santé et d'autres organismes pertinents, dans des collections de directives cliniques et des registres d'essais cliniques, et auprès d'associations nationales et internationales de médecins spécialistes. MéTHODES DE VALIDATION: Le contenu et les recommandations ont été rédigés et acceptés par les auteurs. Les membres du comité de médecine fœto-maternelle ont ensuite passé en revue le contenu et formulé des commentaires aux fins d'examen. Enfin, le conseil d'administration de la Société des obstétriciens et gynécologues du Canada (SOGC) a approuvé la publication de la version définitive de la directive. Les points de désaccord ont été abordés lors de réunions pour enfin arriver à un consensus. La qualité des données et des recommandations a été déterminée à l'aide des critères d'évaluation décrits par le Groupe d'étude canadien sur les soins de santé préventifs. AVANTAGES, PRéJUDICE ET COûTS: La mise en place des recommandations des présentes directives peut améliorer la reconnaissance des fournisseurs de soins obstétricaux relativement aux problèmes qui touchent les personnes enceintes atteintes d'obésité, notamment au moyen de stratégies de prévention clinique; de la communication entre l'équipe de soins de santé, la patiente et la famille; et de la planification de l'équipement et des ressources humaines. Il est à espérer que les organismes régionaux, provinciaux et fédéraux participeront à la formation et au soutien en matière de soins coordonnés pour les personnes enceintes atteintes d'obésité. MISE à JOUR DE LA DIRECTIVE CLINIQUE: Les directives de la SOGC sont automatiquement passées en revue 5 ans après leur publication. Les auteurs peuvent toutefois proposer une autre date de réévaluation s'ils croient qu'une période de 5 ans est trop courte ou trop longue en fonction de leurs connaissances du sujet à titre d'experts en la matière.

PROMOTEURS

La présente directive a été élaborée à l'aide de ressources financées par la SOGC. DéCLARATIONS SOMMAIRES: RECOMMANDATIONS.

Weight Stigma Among Sexual Minority Adults: Findings from a Matched Sample of Adults Engaged in Weight Management

OBJECTIVE

Despite elevated rates of obesity among some groups of sexual minority (SM) adults, research examining weight stigma in this population is scarce.

METHODS

Weight stigma and weight-related health correlates were assessed in SM adults (N = 658) versus heterosexual adults (N = 658) matched on sex, race/ethnicity, age, education, and BMI. Adults enrolled in WW (formerly Weight Watchers) completed digital questionnaires assessing experienced weight stigma, weight bias internalization (WBI), weight cycling, eating self-efficacy, eating to cope, physical activity, and health-related quality of life (HRQOL).

RESULTS

Survey response rates ranged from 0.8% to 3.5%. There were no differences in experienced weight stigma between SM and heterosexual participants; more than two-thirds experienced weight stigma, and more than 50% reported stigma from family, health care providers, teachers and classmates, and community members. Gay men endorsed higher WBI than heterosexual men (β = 0.22, P < 0.001). Regardless of sexual orientation, WBI was associated with poorer mental HRQOL, lower eating self-efficacy, and increased eating to cope, controlling for demographics and BMI.

CONCLUSIONS

Experiencing weight stigma is as common for SM adults as heterosexual adults engaged in weight management, and WBI is associated with maladaptive eating behaviors and poor mental HRQOL. Increased attention to weight stigma and its health implications in SM populations is warranted.

Socioeconomic status throughout life and body mass index: a systematic review and meta-analysis

This article aimed to systematically review the association between socioeconomic status according to the life course models and the body mass index (BMI) in adults. A review was performed following the guidelines of the PRISMA. The studies were identified in the MEDLINE/PubMed, LILACS and Web of Science databases. The eligible articles investigated the association between at least one life course model (risk accumulation, critical period or social mobility) and BMI. In order to assess the quality of the selected articles, the NOS checklist was applied to each study. Eleven articles were selected for the systematic review, and seven articles were selected for the meta-analysis. The average score and the median in the NOS checklist were 6.4, within a maximum possible score of 8 points. The most used model was social mobility. Regarding meta-analysis, there was association between lower life course socioeconomic status and BMI among women. BMI mean difference (MD) was higher among those who remained with low socioeconomic status throughout life when compared with those who maintained a high socioeconomic status (MD: 2.17, 95%CI: 1.48; 2.86). Before that, the BMI MD was higher among those with upward mobility, compared with those who maintained a high socioeconomic status throughout life (MD: 1.20, 95%CI: 0.73; 1.68). The risk of overweight was also higher among women who maintained low socioeconomic status (summary RR: 1.70, 95%CI: 1.05; 2.74); however, according to the GRADE, the studies presented very low quality evidence. For men, no association was observed. Having low socioeconomic status sometime during life is associated with higher BMI in adulthood.

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

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

The Body as an Object of Stigmatization in Cultures of Guilt and Shame: A Polish-Vietnamese Comparison

The aim of this paper is to examine cross-cultural differences in body stigmatization between the individualistic Christian culture of guilt (Poland) and the collectivistic Buddhist/Confucian culture of honor and shame (Vietnam). The study included 1290 university students from Poland (n = 586) and Vietnam (n = 704). Subjects filled in the body esteem scale and the perceived stigmatization questionnaire, and body measurements were collected to calculate anthropometric indices. Participants from Vietnam were less satisfied with their appearance than their Polish peers. Men in both countries assessed themselves more favorably. No anthropometric index predicted body esteem in Vietnamese women, while only indices related to fat levels were predictors in Polish women. Men with a V-shaped body assessed themselves as stronger and as having a better physical condition. A possible explanation of the observed cross-cultural differences is that interdependent self-construal makes young adults in collectivistic societies more susceptible to criticism, and the Confucian values of modesty and shame lead to them not perceiving their bodies as sexual objects. The Christian sense of guilt does not influence the perception of sexuality. Absence of friendly behavior mediated the relation between anthropometric indices and body esteem in both cultures.

NP student encounters with obesity bias in clinical practice

This study explores NP students' encounters with obesity stigma and bias in their clinical environment as well as recommendations to decrease obesity stigma and bias. Results indicate a need for continued education on the topic of weight management within NP curricula.

Experiences of weight-related stigma among low-income rural women of higher weights from the midwestern United States

Weight-related stigma and stereotypes are widespread. Despite established research highlighting the disproportionate disparities rural individuals face, studies focusing on women in rural and low-income environments are underrepresented in the literature. The current study addressed these gaps in the literature using 25 in-depth interviews, which were analyzed using interpretive phenomenological procedures. The research questions were: i) what are low income rural women of higher weights’ understandings and experiences of weight stigma in healthcare? and ii) to what extent do their experiences of stigma affect or do not affect their healthcare-related behaviors? Sixteen women in the study experienced weight-related stigma in healthcare. Many delayed their care while others felt their care was essentially denied. Findings indicate that more can be done to address weight-related stigma.

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

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

Weight stigma and its impact on paediatric care

PURPOSE OF REVIEW

This review aims to evaluate current research findings relevant to weight stigmatization, to acknowledge the deleterious impact it has on the health of the paediatric population and to provide insight to optimize future guidelines for the treatment of individuals with overweight and obesity.

RECENT FINDINGS

Obesity prevalence continues to rise in the USA with estimates in children from ages 2-19 years of 18.5%, an all-time high. With the increase in obesity, there has been a concomitant increase in weight stigma, which affects both youth and general population across varied levels of socioeconomic status and body sizes.

SUMMARY

Weight stigma is a contributing phenomenon to the current obesity epidemic, as individuals with stigmatized experiences (weight-based teasing, bullying, victimization) have increased risks for acquiring adverse health outcomes that encompass the physical, behavioural and psychological. Weight stigma can also lead affected individuals to internalize such experiences which decrease their overall quality of life. Sources of stigma may come from peers, family, educators, media, as well as healthcare professionals, as highlighted in this review. Efforts to establish prevention and treatment strategies for weight stigma may generate further traction to help improve global obesity rates. VIDEO ABSTRACT.

The Impact of Workplace Health Promotion Programs Emphasizing Individual Responsibility on Weight Stigma and Discrimination

Over time, there has been a steady increase of workplace health promotion programs that aim to promote employees' health and fitness. Previous research has focused on such program's effectiveness, cost-savings, and barriers to engaging in workplace health promotion. The present research focuses on a downside of workplace health promotion programs that to date has not been examined before, namely the possibility that they, due to a focus on individual responsibility for one's health, inadvertently facilitate stigmatization and discrimination of people with overweight in the workplace. Study 1 shows that the presence of workplace health promotion programs is associated with increased attributions of weight controllability. Study 2 experimentally demonstrates that workplace health promotion programs emphasizing individual rather than organizational responsibility elicit weight stigma. Study 3, which was pre-registered, showed that workplace health promotion programs emphasizing individual responsibility induced weight-based discrimination in the context of promotion decisions in the workplace. Moreover, focusing on people with obesity who frequently experience weight stigma and discrimination, Study 3 showed that workplace health promotion programs highlighting individual responsibility induced employees with obesity to feel individually responsible for their health, but at the same time made them perceive weight as less controllable. Together, our research identifies workplace health promotion programs as potent catalysts of weight stigma and weight-based discrimination, especially when they emphasize individual responsibility for health outcomes. As such, we offer valuable insights for organizations who aim to design and implement workplace health promotion programs in an inclusive, non-discriminatory way that benefits all employees.

An update on research examining the implications of stigma for access to and utilization of bariatric surgery

PURPOSE OF REVIEW

To summarize recent literature examining the relationship between stigma and utilization of surgical treatments for obesity.

RECENT FINDINGS

The stigma of obesity and stigma associated with surgical treatments for obesity can affect both healthcare providers' recommendations of these options and patients' likelihood of considering and choosing these treatments. Presurgical requirements of healthcare and insurance organizations and a lack of postsurgical support reflect the stigmatizing attitudes that bariatric/metabolic surgery is an 'easy fix' and 'last resort' for patients too undisciplined to lose weight in other ways.

SUMMARY

Here we review the literature published in the last year that addresses the implications of stigma for the utilization and outcomes of surgical treatments for obesity.