Unhealthy weight control behaviors and substance use among adolescent girls: The harms of weight stigma

Does terminology matter when measuring stigmatizing attitudes about weight? Validation of a brief, modified attitudes toward obese persons scale

Objective

Commonly used terms like "obese person" have been identified as stigmatizing by those with lived experience. Thus, this study sought to revise a commonly used measure of weight stigmatizing attitudes, the Attitudes Toward Obese Persons (ATOP) scale.

Methods

The original terminology in the 20-item ATOP (e.g., "obese") was compared to a modified version using neutral terms (e.g., "higher weight"). Participants (N = 832) were randomized to either receive the original or modified ATOP.

Results

There was a statistically significant difference, with a small effect size (d = -0.22), between the scores of participants who received the original ATOP (M = 69.25) and the modified ATOP (M = 72.85), t(414) = -2.27, p = 0.024. Through principal component analysis, the modified ATOP was best used as a brief, 8-item unidimensional measure. In a second sample, confirmatory factor analysis verified the fit of the brief, 8-item factor structure.

Conclusions

Findings suggest that a modified, brief version of the ATOP (ATOP-Heigher Weight; ATOP-HW) with neutral language is suitable for assessing negative attitudes about higher-weight people. The ATOP-HW may slightly underestimate weight stigma compared to the original ATOP, or the language in the ATOP may magnify negative attitudes. Further examination of the terminology used in weight stigma measures is needed to determine how to best assess weight stigma without reinforcing stigmatizing attitudes. The present study's findings suggest that the use of neutral terms in measures of anti-fat bias is a promising solution that warrants further investigation.

Dose-Dependent Association Between Body Mass Index and Mental Health and Changes Over Time

Importance

Overweight and obesity affect 340 million adolescents worldwide and constitute a risk factor for poor mental health. Understanding the association between body mass index (BMI) and mental health in adolescents may help to address rising mental health issues; however, existing studies lack comprehensive evaluations spanning diverse countries and periods.

Objective

To estimate the association between BMI and mental health and examine changes over time from 2002 to 2018.

Design, Setting, and Participants

This was a repeated multicountry cross-sectional study conducted between 2002 and 2018 and utilizing data from the Health Behaviour in School-aged Children (HBSC) survey in Europe and North America. The study population consisted of more than 1 million adolescents aged 11 to 15 years, with all surveyed children included in the analysis. Data were analyzed from October 2022 to March 2023.

Main Outcomes and Measures

Mental health difficulties were measured by an 8-item scale for psychological concerns, scoring from 0 to 32, where a higher score reflects greater psychosomatic issues. BMI was calculated using weight divided by height squared and adjusted for age and sex. Data were fitted by multilevel generalized additive model. Confounders included sex, living with parents, sibling presence, academic pressure, the experience of being bullied, family affluence, screen time, and physical activity.

Results

Our analysis of 1 036 869 adolescents surveyed from 2002 to 2018, with a mean (SD) age of 13.55 (1.64) years and comprising 527 585 girls (50.9%), revealed a consistent U-shaped association between BMI and mental health. After accounting for confounders, adolescents with low body mass and overweight or obesity had increased psychosomatic symptoms compared to those with healthy weight (unstandardized β, 0.14; 95% CI, 0.08 to 0.19; unstandardized β, 0.27; 95% CI, 0.24 to 0.30; and unstandardized β, 0.62; 95% CI, 0.56 to 0.67, respectively), while adolescents with underweight had fewer symptoms (unstandardized β, -0.18; 95% CI, -0.22 to -0.15). This association was observed across different years, sex, and grade, indicating a broad relevance to adolescent mental health. Compared to 2002, psychosomatic concerns increased significantly in 2006 (unstandardized β, 0.19; 95% CI, 0.11 to 0.26), 2010 (unstandardized β, 0.14; 95% CI, 0.07 to 0.22), 2014 (unstandardized β, 0.48; 95% CI, 0.40 to 0.56), and 2018 (unstandardized β, 0.82; 95% CI, 0.74 to 0.89). Girls reported significantly higher psychosomatic concerns than boys (unstandardized β, 2.27; 95% CI, 2.25 to 2.30). Compared to primary school, psychosomatic concerns rose significantly in middle school (unstandardized β, 1.15; 95% CI, 1.12 to 1.18) and in high school (unstandardized β, 2.12; 95% CI, 2.09 to 2.15).

Conclusions and Relevance

Our study revealed a U-shaped association between adolescent BMI and mental health, which was consistent across sex and grades and became stronger over time. These insights emphasize the need for targeted interventions addressing body image and mental health, and call for further research into underlying mechanisms.

Does Terminology Matter When Measuring Stigmatizing Attitudes About Weight? Validation of a Brief, Modified Attitudes Toward Obese Persons Scale

Objective Commonly used terms like "obese person" have been identified as stigmatizing by those with lived experience. Thus, this study sought to revise a commonly used measure of weight stigmatizing attitudes, the Attitudes Toward Obese Persons (ATOP) scale. Methods The original terminology in the 20-item ATOP (e.g., "obese") was compared to a modified version using neutral terms (e.g., "higher weight"). Participants ( N  = 832) were randomized to either receive the original or modified ATOP. Results There was a statistically significant difference, with a low effect size ( d =-0.26), between the scores of participants who received the original ATOP ( M  = 69.25) and the modified ATOP ( M  = 72.85), t (414) = -2.27, p  = .024. Through principal component analysis, the modified ATOP was found to be best used as a brief, 8-item unidimensional measure. In a second sample, confirmatory factor analysis verified the fit of the brief, 8-item factor structure. Conclusions Findings suggest a modified, brief version of the ATOP (ATOP-Heigher Weight; ATOP-HW) with neutral language is suitable for assessing negative attitudes about higher-weight people. The ATOP-HW may slightly underestimate weight stigma compared to the original ATOP. Further examination of the terminology used in weight stigma measures is needed to determine how to best assess weight stigma without reinforcing stigmatizing attitudes. The findings of the present study suggest that the use of neutral terms in measures of anti-fat bias is a promising solution that warrants further investigation.

Identifying methods used to manage weight and shape by first year university students: A qualitative analysis

OBJECTIVE

To identify current strategies used by first-year university students to lose weight, maintain weight, or change their body shape.

METHODS

First-year university students (n = 661) completed an open-ended, web-based survey. Cross-sectional data were analyzed qualitatively using a reflexive thematic approach to identify strategies used to lose weight, maintain weight, or alter body shape/composition. Thematic maps were constructed for each weight- and shape-related goal.

RESULTS

Four main types of strategies were used to achieve all three weight or shape-related goals among first-year college students: changes in diet, changes in exercise, self-monitoring, and disordered eating. One behavioral strategy observed across all weight-related goals was prioritizing protein consumption, including protein gained from supplementation. However, there were also differences in strategies by weight- or shape-related goal. For example, only participants aiming to lose or maintain weight reported mindful strategies for monitoring diet. Individuals aiming to alter body composition reported heterogeneity in goal-related intentions, targeting specific body parts through exercise, and extensive supplement use.

CONCLUSIONS

First-year college students use a variety of strategies to manage their weight and shape. Some strategies were observed across goals, whereas others are specific to the weight- or shape-related goal. More research is needed to understand the impacts, both positive and negative, of using the strategies identified in the present study.

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

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

Perceived stigma in burn survivors: Associations with resourcefulness and alexithymia

OBJECTIVE

Burn survivors often have severe scarring and distorted body image, and they are commonly given new perceptions and even receive a variety of negative labels from individuals, families and society. This study aimed to explore the association between stigma, resourcefulness and alexithymia, and identifies whether resourcefulness in burn survivors is mediating the relationship between resourcefulness and alexithymia.

METHOD

This correlational study was conducted from December 2021 to July 2022 in a comprehensive tertiary Grade A hospital in Ningxia, China. A convenience sample of 159 burn survivors was recruited. Data were collected using demographics, Social Impact Scale(SIC),Toronto Alexithymia Scale, and Resourcefulness Scale (RS). Descriptive analysis, Hierarchical Regression analysis, Pearson Correlation analysis, and Mediation analysis were used for data analysis.

RESULTS

Finally, a data set of 148 responses was determined for analysis. The effective rate was 95.9%. We found significant correlation between stigma, resourcefulness and alexithymia. Sociodemographic characteristics (gender, spouse states), clinical characteristics (body surface burned area, scar areas), resourcefulness and alexithymia of burn survivors were significant predictors of stigma among burn survivors. The mediating effect of resourcefulness between stigma and alexithymia in burns survivors accounted for 36.03% of the total effect.

CONCLUSION

Resourcefulness partially mediates the relationship between stigma and alexithymia. These findings suggest medical staff should strengthen the management of the mental health of burn survivors and eliminate the negative cognition and tendency of burn survivors by regularly promoting stigma counseling measures based on cognitive behavioral therapy. Based on the resourcefulness theory, psychological counseling and intervention are carried out in various ways to fully mobilize their internal factors for positive emotional regulation and enhance the ability of individuals to cope with adversity. In addition, an attempt was made to establish an "anti-stigma coalition" or "peer support group" for burn survivors to provide networked information support and emotional support to facilitate further the smooth return of patients to their families and society.

Using a life course health development framework to combat stigma-related health disparities for individuals with intellectual and/or developmental disability (I/DD)

In the U.S., 1 in 6 children has an intellectual and/or developmental disability (I/DD). This population experiences a multitude of negative health outcomes across the life course, relative to the general population. Stigma-the social devaluation of individuals with certain characteristics, identities, or statuses within interpersonal, educational, healthcare, and policy contexts-is a potentially preventable contributor to health disparities. To date, existing approaches for addressing and preventing stigma are limited to discrete and siloed interventions that often fail to address the lifelong, cumulative impacts of the specific types of stigma experienced by the I/DD population. In the current paper, we describe three elements of Life Course Health Development (LCHD)-a novel translational framework that draws on evidence from biology, sociology, epidemiology, and psychology-that healthcare providers can use to prevent stigma-related health disparities and improve outcomes for individuals with I//DDs. We discuss the utility of targeting prevention to sensitive periods; prioritizing interventions for the most damaging types of stigmas; and leveraging supports from multiple service systems and sectors. By incorporating evidence from life course science into efforts to address stigma-related health disparities, providers can more effectively and strategically prevent and combat stigma-related health disparities for the I/DD population in childhood and across the life course.

The Impact of Teasing and Bullying Victimization on Disordered Eating and Body Image Disturbance Among Adolescents: A Systematic Review

Adolescence is a developmental period in which disordered eating and negative body image are highly prevalent, yet their risk factors are insufficiently understood and targeted. Despite research implicating both teasing and bullying victimization in the development of eating disorders, these strands of research are yet to be integrated. This systematic review hence aimed to identify whether teasing and bullying victimization are associated with greater risk of eating disorders and body image disturbance for adolescents. Systematic searches of PsycINFO and PubMed databases identified 79 papers that included quantitative analyses of the relationship between weight-related or nonspecific teasing or bullying victimization and disordered eating or body image disturbance. Overall, studies indicated that adolescents who are teased or bullied are more likely to experience disordered eating and negative body image compared to nonvictimized adolescents. This was more consistently observed in cross-sectional studies than in longitudinal findings. We identify several methodological limitations of the literature, including the infrequent consideration of potential mediating and moderating variables. Finally, we outline future directions such as temporal sequencing of the complex interrelationships among teasing and bullying, disordered eating, and body image disturbance in adolescents.

The Relationship between Weight Stigma, Physical Appearance Concerns, and Enjoyment and Tendency to Avoid Physical Activity and Sport

Participation in physical activity and sport is on the decline and there is a poor understanding of the psychosocial factors that contribute to people's reluctance to participate. We examined whether there were relationships between factors such as weight stigma, weight bias internalization, appearance evaluation, and fears of negative appearance evaluations, and enjoyment and avoidance of physical activity and sport. Undergraduate students (N = 579) completed a survey assessing demographics, and the variables described above. In hierarchal multivariate regression models, weight stigma (β = -0.16, p < 0.001), appearance evaluation (β = 0.19, p = 0.001), and weight bias internalization (β = -0.19, p = 0.003) were associated with lower enjoyment of physical activity and sport. Weight stigma (β = 0.46, p = 0.001), weight bias internalization (β = 0.42, p = 0.001), and fear of negative appearance evaluations (β = 0.16, p = 0.000) were also significantly associated with the tendency to avoid physical activity and sport. Serial mediation analysis showed the relationship between weight stigma and enjoyment of physical activity and sport was through appearance evaluation and weight bias internalization (indirect effect = -0.007, SE = 0.002, 95% CI = -0.01, -0.02). Similarly, the relationship between weight stigma and avoidance of physical activity and sport was through weight bias internalization and fear of negative appearance evaluations (indirect effect = 0.11, SE = 0.03, 95% CI = 0.05, 0.16). These results suggest that weight stigma and concerns about one's physical appearance influence people's enjoyment and reasoning for avoiding physical activity and sport. Research is needed to identify ways to reduce body-related stigma and increase enjoyment and participation in physical activity and sport.

Relationships between patterns of technology-based weight-related self-monitoring and eating disorder behaviors among first year university students

OBJECTIVE

To identify patterns of technology-based weight-related self-monitoring (WRSM) and assess associations between identified patterns and eating disorder behaviors among first year university students.

METHODS

First year university students (n = 647) completed a web-based survey to assess their use of technology-based WRSM and eating disorder behaviors. The cross-sectional data were analyzed using gender-stratified latent class analysis to identify patterns of WRSM, followed by logistic regression to calculate the predicted probability of eating disorder behaviors for each pattern of WRSM.

RESULTS

Technology-based WRSM is common among first year university students, with patterns of WRSM differing by student gender. Further, unique patterns of WRSM were associated with differing probability of engaging in eating disorder behaviors. For example, compared to the 67.0% of females who did not use technology-based WRSM, females engaging in high amounts of technology-based WRSM (33.0%) were more likely to report fasting, skipping meals, excessively exercising, and using supplements. Among males, those who reported all forms of WRSM (9.5%) were more likely to report fasting, skipping meals, purging, and using supplements but those who only used exercise self-monitoring (11.9%) did not have increased likelihood of eating disorder behaviors.

CONCLUSIONS

Using multiple forms of technology-based WRSM is associated with increased likelihood of engaging in eating disorder behaviors among both female and male, first year university students. Assessing technology-based WRSM may be a simple method to screen for elevated eating disorder risk among first year students.

Complexity and Stigma of Pediatric Obesity

Weight stigma is rooted in a fundamental misunderstanding of the origins of obesity, wherein the interplay of behavioral, environmental, genetic, and metabolic factors is deemphasized. Instead, the widespread societal and cultural presence of weight stigma fosters misconceptions of obesity being solely a result of unhealthy personal choices. Weight stigma is pervasive in childhood and adolescence and can affect individuals throughout their life. Although the prevalence of pediatric obesity remains high throughout the world, it becomes increasingly important to understand how weight stigma affects weight and health outcomes in children and adolescents with overweight or obesity, including in those with rare genetic diseases of obesity. We identified and reviewed recent literature (primarily published since 2000) on weight stigma in the pediatric setting. Articles were identified with search terms including pediatric obesity, weight bias, weight stigma, weight-based teasing and bullying, and weight bias in health care. In this narrative review, we discuss the stigma of pediatric obesity as it relates to the complex etiology of obesity as well as describe best practices for avoiding bias and perpetuating stigma in the health care setting.

The Role of Snack Choices, Body Weight Stereotypes and Smoking Behavior in Assessing Risk Factors for Adolescent Overweight and Obesity

This study investigated the relationship of behavioral factors, such as snack choices, obesity stereotypes and smoking with adolescents’ body weight. Individual-level data for 1254 Greek youths were selected via a formal questionnaire. Snack choices seem to be gender specific with girls showing a stronger preference for healthier snacks. Frequent consumption of high-calorie and more filling snacks was found to increase Body Mass Index (BMI) in both genders. Fruit/vegetable snacks were associated with lower body weight in females, whereas cereal/nut snacks had a negative influence in males’ BMI. The majority of participants expressed anti-fat attitudes and more boys than girls assigned positive attributes to lean peers. The endorsement of the thin-ideal was positively associated with the BMI of both adolescent boys and girls. This study also revealed that neglecting potential endogeneity issues can lead to biased estimates of smoking. Gender may be a crucial moderator of smoking–BMI relationships. Male smokers presented a higher obesity risk, whereas female smokers were more likely to be underweight. Nutrition professionals should pay attention to increase the acceptance of healthy snack options. Gender differences in the influence of weight stereotypes and smoking on BMI should be considered in order to enhance the efficacy of obesity prevention interventions.

Associations Between Weight Perception, Unhealthy Weight Control Behavior, and Suicidal Ideation and Planning Among Korean Adolescents: A National Cross-Sectional Secondary Analysis

PURPOSE

This study aimed to investigate the associations between weight perception, unhealthy weight control behavior, and suicidal ideation and planning and identify the role of unhealthy weight control behavior as a mediator in these associations among Korean adolescents.

DESIGN AND METHODS

This national cross-sectional secondary study used data from the 2015-2017 Korea Youth Risk Behavior Web-Based Surveys, with a final sample of 96,285 adolescents who tried to manage their weight in the 30 days prior to the surveys. A multivariate logistic regression was conducted.

RESULTS

Both adolescent groups who perceived themselves to be underweight or overweight were significantly linked to a greater likelihood of suicidal ideation and planning (COR, 95% CI = 1.249, 1.141-1.367; COR, 95% CI = 1.339, 1.282-1.399) respectively. While adolescents with perceptions of being underweight are associated with suicidal ideation and planning through the suppression effect of unhealthy weight control behavior (Pathway A: OR, 95% CI = 0.628, 0.587-0.671), adolescents with perceptions of being overweight are linked with the same through the mediation effect (Pathway A: OR, 95% CI = 1.195, 1.141-1.251).

CONCLUSIONS

Adolescents with perceptions of being overweight are highly likely to have unhealthy weight control behavior that can be linked to the possibility of suicidal ideation and planning, while adolescents with perceptions of being underweight are comparatively less likely to engage in such behavior.

PRACTICE IMPLICATIONS

It is necessary to identify the status of weight perception among adolescents and closely monitor the unhealthy weight control behavior to prevent suicidal ideation and planning.

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.