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Akyirem S, Ekpor E, Namumbejja Abwoye D, Wang K. Weight-related discrimination, perceived stress and psychological and physical well-being of persons with type 2 diabetes: A mediation analysis. Diabet Med 2024; 41:e15322. [PMID: 38561918 PMCID: PMC11088521 DOI: 10.1111/dme.15322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Accepted: 03/19/2024] [Indexed: 04/04/2024]
Abstract
AIMS The aim of the study was to examine perceived stress as a mediator of the association between weight-related discrimination and physical and psychological well-being among persons with type 2 diabetes (T2D). METHODS Data were obtained from 5104 persons with self-reported T2D participating in the All of Us research programme in the United States. The Everyday Discrimination Scale, Cohen's Perceived Stress Scale (PSS) and PROMIS Global Health Scale were used to measure weight-related discrimination, perceived stress and health outcomes (physical and psychological), respectively. Mediation effects of PSS were tested by bootstrapping with 5000 random samples. RESULTS Participants were, on average, 63.62 (SD 11.38) years old. Majority of them were female (55.53%), non-Hispanic White (72.61%), married or living with a partner (56.92%), had a household income of <$35,000 (31.99%) and had some college education (33.54%). We found that approximately 18% of study participants reported having experienced weight-related discrimination. We also found that weight-related discrimination was independently associated with poor physical and psychological well-being. These associations were partially mediated by perceived stress such that weight-related discrimination was associated with greater perceived stress, which was in turn associated with poorer physical and psychological well-being. CONCLUSIONS Given that weight-related discrimination is associated with poor outcomes through elevated stress, interventions that target stress may disrupt this pathway thereby helping to reduce the health impact of weight-related discrimination. This assertion should, however, be tested in future studies.
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Affiliation(s)
- Samuel Akyirem
- Yale School of Nursing, Yale University, West Haven, Connecticut 06519, USA
| | - Emmanuel Ekpor
- School of Nursing and Midwifery, University of Ghana, Accra, Ghana
| | | | - Katie Wang
- Yale School of Public Health, Yale University, New Haven, Connecticut 06511, USA
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Busili A, Kumar K, Kudrna L, Busaily I. The risk factors for mental health disorders in patients with type 2 diabetes: An umbrella review of systematic reviews with and without meta-analysis. Heliyon 2024; 10:e28782. [PMID: 38617916 PMCID: PMC11015102 DOI: 10.1016/j.heliyon.2024.e28782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 03/22/2024] [Accepted: 03/25/2024] [Indexed: 04/16/2024] Open
Abstract
Background Patients with type 2 diabetes have a nearly twofold higher rate of diagnosed mental disorders than those without diabetes. The association between type 2 diabetes and mental disorders is well established in the literature and recognized as a bidirectional relationship. This study aims to conduct an umbrella review of risk and protective factors for mental health disorders in patients with type 2 diabetes and assess the credibility of the evidence for the association between each factor and mental health disorders. Methods A comprehensive search was conducted of Medline via PubMed, Web of Science, EMBASE, CINHAL, and PsycINFO from inception to November 17, 2022, to identify systematic reviews with and without meta-analyses examining associations of factors with mental health disorders in patients with type 2 diabetes. For each association, we recalculated the summary effect size and 95% confidence intervals using random-effects models. We also reported the 95% prediction interval and between-group heterogeneity. Results The study included 11 systematic reviews that met the inclusion criteria, comprising eight meta-analyses and three without meta-analyses. This involved approximately 489,930 participants and encompassed 26 unique factors. Six factors were rated as having suggestive evidence at the Class III level. These factors were obesity (n = 18,456, OR 1.75 [1.2 to 2.59], I2 97.7%), neuropathy (n = 3898, OR 2.01 [1.60 to 2.54], I2 44.5%), diabetes complications (n = 1769, OR 1.90 [1.53 to 2.36], I2 39.3%), peripheral blood concentrations of CRP (n = 1742, SMD 0.31 [0.16 to 0.45], I2 84.1%), female sex (n = 35,162, OR 1.36 [1.19 to 1.54], I2 64.5%), and social support (n = 3151, OR 2.02 [1.51 to 2.70], I2 87.2%). Conclusions Several factors associated with mental health disorders in patients with type 2 diabetes were identified with varying degrees of supporting evidence. Significantly, obesity, neuropathy, complications, peripheral blood CRP concentrations, female sex, and social support emerged with suggestive evidence. An investigation of these factors should be conducted to target interventions accordingly. It may be helpful to prioritize patients who have these risk factors as high-risk groups and to implement plans and policies to enhance support before mental health disorders occur.
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Affiliation(s)
- Amani Busili
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Kanta Kumar
- Institute of Clinical Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Laura Kudrna
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Idris Busaily
- Lecture, College of Dentistry, Jazan University, Jazan, Kingdom of Saudi Arabia
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Guo X, Wu S, Tang H, Li Y, Dong W, Lu G, Liang S, Chen C. The relationship between stigma and psychological distress among people with diabetes: a meta-analysis. BMC Psychol 2023; 11:242. [PMID: 37620853 PMCID: PMC10463375 DOI: 10.1186/s40359-023-01292-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 08/21/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND & AIMS Diabetes may perceive or experience varying degrees of stigma and psychological distress. The association between diabetes-related stigma and psychological distress has been examined in many studies, but no research has used a quantitative synthesis method to investigate the severity of this association and the moderators of the relationship. Thus, we conducted a meta-analysis to quantitatively integrate previous findings to identify the magnitude of the association between stigma and psychological distress among people with diabetes. REVIEW METHODS Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines, we systematically searched four English academic databases (PubMed, Embase, Web of Science, and PsycINFO) and three Chinese databases (China National Knowledge Infrastructure [CNKI], WANFANG Data, China Science and Technology Journal Database [VIP]). The databases were searched from the inception of each database to the end of March 2023. The pooled correlation coefficient of the association between stigma and psychological distress among people with diabetes was calculated by a random effects model using Stata software (version 17.0), and several moderators that impacted this relationship were identified. RESULTS Eligible studies (N = 19) with a total of 12,777 participants were analysed. The pooled correlation was high between diabetes-related stigma and psychological distress (r = 0.50, 95% CI: [0.43-0.57]). Moreover, the association was moderated by the diabetes stigma measurement tools and diabetes distress measurement tools used. However, the relationship was not moderated by type of diabetes, age, gender, geographical location, or type of stigma. CONCLUSIONS The results of the meta-analysis showed that stigma is strongly related to psychological distress among people with diabetes. Longitudinal or experimental research should be expanded in the future to further identify the causal pathways in the relationship between diabetes stigma and diabetes distress.
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Affiliation(s)
- Xiajun Guo
- Institute of Nursing and Health, School of Nursing and Health, Henan University, Kaifeng, 475004, Henan, China
| | - Sijia Wu
- Institute of Nursing and Health, School of Nursing and Health, Henan University, Kaifeng, 475004, Henan, China
| | - Haishan Tang
- Institute of Nursing and Health, School of Nursing and Health, Henan University, Kaifeng, 475004, Henan, China
| | - Yuanyuan Li
- Institute of Nursing and Health, School of Nursing and Health, Henan University, Kaifeng, 475004, Henan, China
| | - Wanglin Dong
- Institute of Nursing and Health, School of Nursing and Health, Henan University, Kaifeng, 475004, Henan, China
| | - Guangli Lu
- Institute of Business Administration, School of Business, Henan University, Jinming Avenue, Kaifeng, 475004, Henan, China
| | - Shuang Liang
- Institute of Nursing and Health, School of Nursing and Health, Henan University, Kaifeng, 475004, Henan, China.
| | - Chaoran Chen
- Institute of Nursing and Health, School of Nursing and Health, Henan University, Kaifeng, 475004, Henan, China.
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Bennett BL, Puhl RM. Diabetes stigma and weight stigma among physicians treating type 2 diabetes: Overlapping patterns of bias. Diabetes Res Clin Pract 2023; 202:110827. [PMID: 37451627 DOI: 10.1016/j.diabres.2023.110827] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 06/29/2023] [Accepted: 07/12/2023] [Indexed: 07/18/2023]
Abstract
AIMS Adults with type 2 diabetes (T2D) report experiencing stigma across multiple settings, including stigmatizing interactions with their healthcare providers. However, research examining physician biases toward patients with T2D is scarce. Identifying stigma-related barriers in diabetes care is essential to prevent providers' biases from impairing health care delivery. This study assessed attitudes towards individuals with T2D and obesity among physicians who treat T2D. METHODS Physicians specializing in internal medicine or endocrinology (n=205) completed a series of online questionnaires assessing their attitudes towards patients with T2D and obesity, and their attributions of controllability and blame of individuals with T2D and obesity. RESULTS While 85% of physicians felt professionally prepared and confident to treat patients with T2D, 1/3 reported being repulsed by patients with T2D and view them as lazy (39%), lacking motivation (44%), and non-compliant with treatment (44%). Many witnessed professionals in their field making negative comments about patients with T2D (44%). Physicians endorsed worse levels of bias towards patients with obesity than T2D, but differences were small. CONCLUSIONS Findings highlight the need for stigma reduction interventions for physicians addressing both T2D and obesity. Research assessing the effects of T2D stigma on quality of patient care and health outcomes is needed.
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Affiliation(s)
- Brooke L Bennett
- Rudd Center for Food Policy & Health, University of Connecticut, 1 Constitution Plaza, Suite 600, Hartford, CT 06103, USA.
| | - Rebecca M Puhl
- Rudd Center for Food Policy & Health, University of Connecticut, 1 Constitution Plaza, Suite 600, Hartford, CT 06103, USA; Department of Human Development and Family Sciences, University of Connecticut, 348 Mansfield Road, U-1058, Storrs, CT 06269-1058, USA.
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Abstract
Weight stigma is prevalent with negative consequences for health and well-being. This problem is present in health care; stigmatizing attitudes toward patients with obesity are expressed by medical professionals across diverse specialties and patient care settings. This article summarizes the ways in which weight stigma creates barriers to effective care, including poor patient-provider communication, reduced quality of care, and healthcare avoidance. Priorities for stigma reduction in healthcare are discussed, with a clear need for multifaceted approaches and inclusion of people with obesity whose perspectives can inform strategies to effectively remove bias-related barriers to patient care.
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Affiliation(s)
- Rebecca M Puhl
- Rudd Center for Food Policy & Health, University of Connecticut, One Constitution Plaza, Suite 600, Hartford, CT 06103, USA; Department of Human Development & Family Sciences, University of Connecticut, Storrs, CT, USA.
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Telaak SH, Costabile KA, Persky S. The influence of weight on psychosocial well-being in diabetes. BMC Psychol 2023; 11:139. [PMID: 37120583 PMCID: PMC10148990 DOI: 10.1186/s40359-023-01185-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 04/23/2023] [Indexed: 05/01/2023] Open
Abstract
BACKGROUND Individuals with diabetes experience a wide variety of psychosocial responses to their illness due, in part, to the nature of type 1 and type 2 diabetes. Variation in patient weight may play a central role in these differences, yet its influence on psychosocial variation is largely unknown. The current study investigates the relationship between patients' perceived weight status and aspects of psychosocial well-being among individuals with type 1 diabetes (T1D) and type 2 diabetes (T2D). METHODS Individuals who were diagnosed with type 1 or type 2 diabetes were assessed via an online survey from the Diabetes, Identity, Attributions, and Health Study. Participants were categorized into a lower v. higher weight status group based on their self-reported perceived weight. Analyses of covariance were conducted to assess differences in measures of disease onset blame, diabetes stigma, and identity concerns among diabetes type and perceived weight status. Covariates included in our models were gender, age, education, and time since diagnosis. Bonferroni correction was used for post-hoc tests to assess any significant interactions found in our models. RESULTS Findings indicated that weight moderates multiple psychosocial outcomes pertinent to illness experience. Those with T2D and lower weight blamed themselves less for their disease onset, while those with higher weight felt blamed more for their disease onset by others, regardless of diabetes type. Individuals with T1D and higher weight were more frequently and more concerned about being mistaken for having the other disease type (i.e., T2D) compared to those with lower weight. CONCLUSIONS Weight is a key influence on the psychosocial outcomes for people with diabetes, but it operates differently in type 1 versus type 2 diabetes. By further examining the unique interaction between disease type and weight status we may be able to improve psychological well-being among affected individuals of all sizes.
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Affiliation(s)
- Sydney H Telaak
- Social and Behavioral Research Branch, National Human Genome Research Institute, NIH, 31 Center Drive, B1B36, Bethesda, MD, 20892, USA
| | - Kristi A Costabile
- Department of Psychology, Iowa State University, Lagomarcino Hall, 901 Stange Road, Ames, IA, 50011, USA
| | - Susan Persky
- Social and Behavioral Research Branch, National Human Genome Research Institute, NIH, 31 Center Drive, B1B36, Bethesda, MD, 20892, USA.
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Omodara DA, Gibson L, Bowpitt G. Exploring the impact of cultural beliefs in the self-management of type 2 diabetes among Black sub-Saharan Africans in the UK - a qualitative study informed by the PEN-3 cultural model. Ethn Health 2022; 27:1358-1376. [PMID: 33546564 DOI: 10.1080/13557858.2021.1881764] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 01/21/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE The purpose of this study was to examine cultural beliefs, attitudes, and practices of Black sub-Saharan Africans (BsSAs) in the UK regarding their type 2 diabetes (T2D) self-management using the concepts of the PEN-3 cultural model. METHOD A qualitative study involved 36 semi-structured interviews with BsSAs living with T2D in the UK to examine relevant cultural practices and beliefs that have contributed to the uneven burden of self-management behaviours. A narrative thematic analysis of the data was then conducted for the study using NVivo software and guided by the PEN-3 cultural model, which moves beyond individualistic health behaviour models of diabetes but centralises culture in understanding health behaviours. RESULTS Cultural perceptions and self-management behaviours of T2D varied among the BsSAs. Systems of self-management and treatment practices that were congruent with their cultural beliefs and personal priorities were seen as essential in the positive response to self-managing T2D. Knowledge and perceptions of non-conventional and alternative remedies linked to cultural beliefs reflected the existential health-seeking behaviours, and the significance attached to BsSAs negotiated cultural identities and collective practices within the communities. Social network supports were seen as enablers while advice and regimens from healthcare professionals (HCPs) were presented as medicalised and devoid of cultural sensitivities to respondents. CONCLUSION The study findings highlight the need to be not only aware of the negative impact of diabetes perceptions and health behaviours among the BsSA communities, but also be aware of the enabling factors and collective practices within the communities that are equally critical in influencing the self-management and health-seeking decisions of BsSAs living with T2D. PEN-3 model was significant with exploring not only how cultural context shapes health beliefs and practices, but also how social networks and systems play a critical role in enabling or nurturing positive health behaviours and health outcomes.
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Affiliation(s)
- D A Omodara
- Sociology, Nottingham Trent University, Nottingham, UK
| | - L Gibson
- Sociology, Nottingham Trent University, Nottingham, UK
| | - G Bowpitt
- Social Work and Health, Nottingham Trent University, Nottingham, UK
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Lawrence JA, Kawachi I, White K, Bassett MT, Priest N, Masunga JG, Cory HJ, Mita C, Williams DR. A systematic review and meta-analysis of the Everyday Discrimination Scale and biomarker outcomes. Psychoneuroendocrinology 2022; 142:105772. [PMID: 35490482 DOI: 10.1016/j.psyneuen.2022.105772] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 03/01/2022] [Accepted: 04/17/2022] [Indexed: 02/08/2023]
Abstract
Discrimination has consistently been associated with multiple adverse health outcomes. Like other psychosocial stressors, discrimination is thought to impact health through stress-related physiologic pathways including hypothalamic-pituitary-adrenal (HPA) axis activation, dysregulation of inflammation responses, and accelerated cellular aging. Given growing attention to research examining the biological pathways through which discrimination becomes embodied, this systematic review and meta-analysis synthesizes empirical evidence examining relationships between self-reported discrimination and four biomarker outcomes (i.e., cortisol, C-reactive protein (CRP), interleukin-6 (IL-6), and telomere length) among studies that have used the Everyday Discrimination Scale. We conducted a systematic review of studies discussing self-reported, everyday, or chronic discrimination in the context of health by searching Medline / PubMed (National Library of Medicine, NCBI), PsycInfo (APA, Ebsco) and Web of Science Core Collection (Clarivate). Twenty-five articles met the criteria for meta-analysis, with several reporting on multiple outcomes. Discrimination was associated with elevated CRP levels (r = 0.11; 95% CI: 0.01, 0.20, k = 10), though not cortisol (r = 0.05; 95% CI: -0.06, 0.16, k = 9), IL-6 (r = 0.05; 95% CI: -0.32, 0.42, k = 5), or telomere length (r = 0.03; 95% CI: -0.01, 0.07, k = 6). We identify several points of consideration for future research including addressing heterogeneity in assessment of biomarker outcomes and the need for longitudinal assessments of relationships between discrimination and biomarker outcomes.
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Puhl RM, Himmelstein MS, Speight J. Weight Stigma and Diabetes Stigma: Implications for Weight-Related Health Behaviors in Adults With Type 2 Diabetes. Clin Diabetes 2022; 40:51-61. [PMID: 35221472 PMCID: PMC8865787 DOI: 10.2337/cd20-0071] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
There has been little recognition that people with type 2 diabetes are vulnerable to weight stigma and diabetes stigma and almost no research examining the implications of these forms of stigma for their health and well-being. This study examined health behavior correlates of weight stigma and diabetes stigma in 1,227 adults with type 2 diabetes. Results showed that experiencing weight stigma in health care, experiencing differential treatment from others because of their diabetes, and engaging in self-stigma for diabetes and body weight were each significantly associated with increased frequency of binge eating and eating as a coping strategy to deal with negative feelings. Internalizing weight stigma was also significantly associated with lower levels of physical activity and worse self-rated health. These findings suggest that initiatives to improve the health and well-being of people with type 2 diabetes must consider the potentially harmful roles of weight stigma and diabetes stigma.
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Affiliation(s)
- Rebecca M. Puhl
- Rudd Center for Food Policy & Obesity, University of Connecticut, Hartford, CT
- Department of Human Development & Family Sciences, University of Connecticut, Storrs, CT
- Corresponding author: Rebecca M. Puhl,
| | | | - Jane Speight
- Deakin University, School of Psychology, Geelong, Victoria, Australia
- Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Melbourne, Australia
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Pearl RL, Wadden TA, Jakicic JM. Is weight stigma associated with physical activity? A systematic review. Obesity (Silver Spring) 2021; 29:1994-2012. [PMID: 34747131 PMCID: PMC8612947 DOI: 10.1002/oby.23274] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 07/17/2021] [Accepted: 07/26/2021] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Weight stigma is associated with impaired health, attributed in part to reductions in health-promoting behaviors. This review analyzed evidence of the association between weight stigma and physical activity (PA) in adults and youth. METHODS Three databases were searched for terms related to weight stigma and PA. Eligible studies reported the quantitative association between at least one measure of weight stigma and one behavioral measure of PA. RESULTS A total of 38 studies met eligibility criteria. Of the 29 studies of adults, 3 used objective PA measures, and 79% used an observational, cross-sectional design. Findings of the relationship between weight stigma and PA were mixed. Everyday weight discrimination and internalizing weight stigma were associated with reduced PA in most studies. Several studies found indirect, and not direct, effects of weight stigma on PA when analyses included other individual-level factors. In the nine studies of youth, two used objective PA measures, all were observational, and only one study was longitudinal. Most youth studies found a relationship between weight-based teasing and reduced PA. CONCLUSIONS Weight teasing, everyday discrimination, and internalization were associated with reduced PA. However, associations were inconsistent and often indirect. Future studies should include objective PA measures with larger samples and longitudinal assessments.
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Affiliation(s)
- Rebecca L. Pearl
- Department of Clinical and Health Psychology, University of Florida, Gainesville, FL, USA
- Center for Weight and Eating Disorders, Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Thomas A. Wadden
- Center for Weight and Eating Disorders, Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - John M. Jakicic
- Healthy Lifestyle Institute and Physical Activity and Weight Management Research Center, University of Pittsburgh, Pittsburgh, PA, USA
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Pearl RL, Puhl RM, Himmelstein MS, Pinto AM, Foster GD. Weight Stigma and Weight-Related Health: Associations of Self-Report Measures Among Adults in Weight Management. Ann Behav Med 2021; 54:904-914. [PMID: 32333673 DOI: 10.1093/abm/kaaa026] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Weight stigma impairs health. Few studies have disentangled the associations of experienced versus internalized stigma with weight-related outcomes. PURPOSE To examine weight and health variables associated with weight stigma experiences and internalization in the largest-to-date sample of adults in weight management. METHODS WW (formerly Weight Watchers) members (N = 18,769, 94.6% female, 91.1% white) completed an online survey from 2017 to 2018. Participants reported whether they had experienced weight stigma and, if so, the onset, past-year frequency and distress, and interpersonal sources of stigma. Participants completed the Modified Weight Bias Internalization Scale (WBIS-M) and self-reported: past-year weight and lifetime weight cycles; current self-monitoring behaviors; eating self-efficacy; physical activity; perceived stress; eating to cope; body image; and mental and physical health-related quality-of-life (HRQOL). Participants reported their demographic characteristics, including height and weight to compute body mass index. RESULTS In logistic and linear regression analyses (controlling for participant characteristics), WBIS-M scores were negatively associated with weight loss, self-monitoring, eating self-efficacy, body image, and mental HRQOL and positively associated with weight gain, weight cycling, perceived stress, and eating to cope (p < .001). Experiencing weight stigma was associated with greater weight loss and less weight gain, although associations with other variables had small effect sizes (absolute β values < 0.10). WBIS-M scores remained significantly associated with all variables when including stigma onset, frequency/distress, and sources. CONCLUSIONS Internalized, but not experienced, weight stigma was consistently associated with adverse weight and health factors. Developing and testing interventions targeting internalized stigma in the context of weight management should be a research priority.
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Affiliation(s)
- Rebecca L Pearl
- Center for Weight and Eating Disorders, Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Rebecca M Puhl
- Department of Human Development and Family Sciences, University of Connecticut, Storrs, CT, USA.,Rudd Center for Food Policy and Obesity, University of Connecticut, Hartford, CT, USA
| | - Mary S Himmelstein
- Rudd Center for Food Policy and Obesity, University of Connecticut, Hartford, CT, USA.,Department of Psychological Sciences, Kent State University, Kent, OH, USA
| | - Angela M Pinto
- Science Department, WW (formerly Weight Watchers) International, Inc., New York, NY, USA.,Department of Psychology, Baruch College, City University of New York, New York, NY, USA
| | - Gary D Foster
- Center for Weight and Eating Disorders, Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,Science Department, WW (formerly Weight Watchers) International, Inc., New York, NY, USA
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12
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Meanley SP, Plankey MW, Matthews DD, Hawk ME, Egan JE, Teplin LA, Shoptaw SJ, Surkan PJ, Stall RD. Lifetime Prevalence and Sociodemographic Correlates of Multifactorial Discrimination Among Middle-Aged and Older Adult Men Who Have Sex with Men. J Homosex 2021; 68:1591-1608. [PMID: 31860386 PMCID: PMC7305044 DOI: 10.1080/00918369.2019.1702353] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
This study describes multifactorial discrimination (discrimination attributed to multiple social identities) among middle-aged and older adult MSM. MSM aged 40+ years (N = 1,193) enrolled in the Multicenter AIDS Cohort Study completed behavioral surveys ascertaining experiences of discrimination and their social identity attributions. Non-proportional odds regressions assessed multifactorial discrimination by age, race/ethnicity, HIV status, and covariates. Twenty-seven percent of participants reported multifactorial discrimination. Adjusted models indicated that middle-aged men were more likely to report multifactorial discrimination compared to older adult men. Racial/ethnic minorities were more likely to report multifactorial discrimination compared to non-Hispanic white participants. These same patterns emerged among the sub-sample of participants living with HIV. To our knowledge, this is the first assessment of multifactorial discrimination in middle-aged and older MSM. Our findings support the deleterious association between multiple-marginalization and multifactorial discrimination. Multilevel interventions targeting interconnected experiences of stigma may improve the health of MSM in transition to older age.
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Affiliation(s)
- Steven P. Meanley
- University of Pennsylvania School of Nursing, Department of Family and Community Health, Philadelphia, PA
| | - Michael W. Plankey
- Georgetown University Department of Medicine, Division of Infectious Diseases, Washington, DC
| | - Derrick D. Matthews
- University of Pittsburgh Graduate School of Public Health, Department of Infectious Diseases and Microbiology, Pittsburgh, PA
| | - Mary E. Hawk
- University of Pittsburgh Graduate School of Public Health, Department of Behavioral and Community Health Sciences, Pittsburgh, PA
| | - James E. Egan
- University of Pittsburgh Graduate School of Public Health, Department of Behavioral and Community Health Sciences, Pittsburgh, PA
| | - Linda A. Teplin
- Northwestern University Feinberg School of Medicine, Department of Psychiatry and Behavioral Sciences, Chicago, IL
| | - Steven J. Shoptaw
- University of California – Los Angeles, Department of Family Medicine and Psychiatry and Biobehavioral Sciences, Los Angeles, CA
| | - Pamela J. Surkan
- Johns Hopkins University Bloomberg School of Public Health, Department of International Health, Baltimore, MD
| | - Ron D. Stall
- University of Pittsburgh Graduate School of Public Health, Department of Behavioral and Community Health Sciences, Pittsburgh, PA
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Siqueira BB, Assumpção MC, Barroso SM, Japur CC, Penaforte FRDO. Weight stigma and health – Repercussions on the health of adolescents and adults: integrative review of the literature. J bras psiquiatr 2021. [DOI: 10.1590/0047-2085000000324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
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.
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Himmelstein MS, Puhl RM. At multiple fronts: Diabetes stigma and weight stigma in adults with type 2 diabetes. Diabet Med 2021; 38:e14387. [PMID: 32799378 DOI: 10.1111/dme.14387] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 06/25/2020] [Accepted: 08/12/2020] [Indexed: 12/24/2022]
Abstract
AIM The diabetes and obesity fields have called for attention to the harmful role of stigma in obesity and diabetes, especially given that little is known about the extent and nature of diabetes stigma facing adults with type 2 diabetes, or the experience of weight stigma in this population. This study addresses this research gap by examining the prevalence and demographic correlates of weight stigma and diabetes stigma in individuals with type 2 diabetes. METHODS Adults (N = 1212, Mage = 52) with type 2 diabetes living in the USA were recruited by a healthcare-oriented market research firm, and completed online questionnaires to assess their experiences with weight stigma and diabetes stigma, as well as their internalization of both forms of stigma. Rates of stigma and sociodemographic correlates (years with type 2 diabetes, age, education, income, gender, race and BMI) were examined. RESULTS More than half of participants reported prior experiences of weight stigma, and 40-60% reported experiencing weight stigma in a healthcare context. Participants reported frequent experiences with diabetes-related stigma including blame and judgement, self-stigma and differential treatment. Women reported more weight stigma than men, and White women appeared particularly at risk for experiencing weight and diabetes related stigma relative to Black women. CONCLUSIONS Individuals with type 2 diabetes reported higher rates of weight stigma than the general population, experienced high rates of diabetes-related stigma, and many internalized these forms of stigma. Increased attention to stigma reduction is essential to ensuring equitable care for individuals with type 2 diabetes.
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Affiliation(s)
- M S Himmelstein
- Department of Psychological Sciences, Kent State University, Kent, OH, USA
| | - R M Puhl
- Department of Human Development and Family Sciences, University of Connecticut, Storrs, CT, USA
- Rudd Center for Food Policy and Obesity, University of Connecticut, Hartford, CT, USA
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Clair C, Augsburger A, Birrer P, Locatelli I, Schwarz J, Greub G, Zanchi A, Jacot-Sadowski I, Puder JJ. Assessing the efficacy and impact of a personalised smoking cessation intervention among type 2 diabetic smokers: study protocol for an open-label randomised controlled trial (DISCGO-RCT). BMJ Open 2020; 10:e040117. [PMID: 33444198 PMCID: PMC7678377 DOI: 10.1136/bmjopen-2020-040117] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION Few studies have assessed the efficacy of smoking cessation interventions in individuals with type 2 diabetes, but interventions adapted to the specific needs of this population are warranted. The aim of this study is to assess the efficacy of a smoking cessation intervention in a population of smokers with type 2 diabetes and to measure the metabolic impact of smoking cessation. METHODS AND ANALYSIS The study is an open-label, randomised control trial. Participants recruited from a sanitary region of Switzerland will be randomly allocated to either the intervention or the control arm. The intervention group will have four individual counselling sessions over 12 weeks. Trained research nurses will conduct the behavioural intervention, using motivational interviews and addressing diabetes and gender specificities. The control group will have one short counselling session at baseline and will be given written information on smoking cessation. Both groups will have a follow-up visit at 26 and 52 weeks. Demographic and medical data will be collected at baseline and follow-up, along with blood and urine samples. The primary study outcome is continuous smoking abstinence validated by expired-air carbon monoxide from week 12 to week 52. Secondary study outcomes are continuous and 7-day point prevalence smoking abstinence at 12 and 26 weeks; change in motivation to quit and cigarette consumption; and change in glycosylated haemoglobin levels, body weight, waist circumference and renal function after smoking cessation. In a subsample of 80 participants, change in stool microbiota from baseline will be measured at 3, 8 and 26 weeks after smoking cessation. ETHICS AND DISSEMINATION Ethical approval has been obtained by the competent ethics committee (Commission cantonale d'éthique de la recherche sur l'être humain, CER-VD 2017-00812). The results of the study will be disseminated through publications in peer-reviewed journals and conference presentations. TRIAL REGISTRATION NUMBERS ClinicalTrials.gov NCT03426423 and SNCTP000002762; Pre-results.
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Affiliation(s)
- Carole Clair
- Department of Training, Research and Innovation, Center for Primary Care and Public Health, Lausanne, Vaud, Switzerland
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Aurélie Augsburger
- Department of Training, Research and Innovation, Center for Primary Care and Public Health, Lausanne, Vaud, Switzerland
| | - Priska Birrer
- Department of Training, Research and Innovation, Center for Primary Care and Public Health, Lausanne, Vaud, Switzerland
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Isabella Locatelli
- Department of Training, Research and Innovation, Center for Primary Care and Public Health, Lausanne, Vaud, Switzerland
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Joelle Schwarz
- Department of Training, Research and Innovation, Center for Primary Care and Public Health, Lausanne, Vaud, Switzerland
| | - Gilbert Greub
- Center for Research on Intracellular Bacteria, Institute of Microbiology, University Hospital of Lausanne, Lausanne, Switzerland
| | - Anne Zanchi
- Service of Nephrology and Hypertension, Service of Endocrinology, Diabetes and Metabolism, University Hospital of Lausanne Department of Medicine, Lausanne, Switzerland
| | - Isabelle Jacot-Sadowski
- Department of Health Promotion and Prevention, Center for Primary Care and Public Health, Lausanne, Vaud, Switzerland
| | - Jardena J Puder
- Service of Obstetrics, Department Woman Mother Child, University Hospital of Lausanne, Lausanne, Vaud, Switzerland
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Giménez Garcia-Conde M, Marin L, Ruiz de Maya S, Cuestas PJ. Parental Attitudes to Childhood Overweight: The Multiple Paths through Healthy Eating, Screen Use, and Sleeping Time. Int J Environ Res Public Health 2020; 17:ijerph17217885. [PMID: 33121180 PMCID: PMC7662269 DOI: 10.3390/ijerph17217885] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 10/23/2020] [Accepted: 10/24/2020] [Indexed: 12/26/2022]
Abstract
The main goal of this paper is to examine how parental attitudes toward sleeping, screen use, and feeding their child influence the child's body mass index (BMI) through the child's behaviors related to time dedicated to sleep and television, and their healthy eating. Using survey data from 908 parents, results show that parental attitudes have a significant influence on children's behavior and, more importantly, on their BMI. The three forms of a child's behavior (sleeping, watching TV, and healthy eating patterns) are affected by what parents do and their attitudes toward these three behaviors at home. Results show how changes in parental attitudes are an interesting target to prevent the child's overweight.
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Snyder M, Haskard-Zolnierek K, Howard K, Hu Y. Weight stigma is associated with provider-patient relationship factors and adherence for individuals with hypothyroidism. J Health Psychol 2020; 27:702-712. [PMID: 33081509 DOI: 10.1177/1359105320963548] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
The goal of this study was to examine weight stigma experiences during medical visits as related to provider-patient relationship factors and adherence among individuals with hypothyroidism. A total of 362 participants recruited via social media participated in an online survey. Regression and mediation analyses indicated that weight stigma was negatively associated with adherence; this relationship was mediated by decreased trust in provider, less perceived provider empathy, and lower provider-patient depth-of-relationship. Structural equation modeling with BMI controlled revealed that weight stigma is associated with worsened provider-patient relationship and adherence. Findings suggest the importance of eliminating weight stigma experiences for patients.
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Affiliation(s)
| | | | | | - Yueqin Hu
- Texas State University, San Marcos, TX, USA
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Puhl RM, Himmelstein MS, Hateley-Browne JL, Speight J. Weight stigma and diabetes stigma in U.S. adults with type 2 diabetes: Associations with diabetes self-care behaviors and perceptions of health care. Diabetes Res Clin Pract 2020; 168:108387. [PMID: 32858100 DOI: 10.1016/j.diabres.2020.108387] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 06/17/2020] [Accepted: 08/19/2020] [Indexed: 01/18/2023]
Abstract
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.
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Affiliation(s)
- Rebecca M Puhl
- Department of Human Development & Family Sciences, University of Connecticut, Storrs, CT, United States; Rudd Center for Food Policy & Obesity, University of Connecticut, Hartford, CT, United States.
| | - Mary S Himmelstein
- Department of Psychological Sciences, Kent State University, Kent, OH, United States
| | | | - Jane Speight
- Deakin University, School of Psychology, Geelong, Victoria, Australia; The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Melbourne, Australia
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Gerend MA, Sutin AR, Terracciano A, Maner JK. The role of psychological attribution in responses to weight stigma. Obes Sci Pract 2020; 6:473-483. [PMID: 33082989 PMCID: PMC7556435 DOI: 10.1002/osp4.437] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 05/31/2020] [Accepted: 06/07/2020] [Indexed: 11/24/2022] Open
Abstract
Objective Weight discrimination is associated with numerous negative health consequences. Little is known about early‐stage psychological mechanisms that explain variability in responses to weight discrimination among people with obesity. This study tested the hypothesis that attributing negative social evaluation to one's weight would be associated with stigma‐related stress responses (eg, reduced cognitive functioning and self‐esteem, increased negative affect and cortisol), especially among people who had experienced frequent weight discrimination in the past. Methods Adults (N = 109) with obesity were randomly assigned to receive a mildly positive (control) versus negative social evaluation. The extent to which participants attributed the negative evaluation to their physical appearance was assessed, along with negative affect, social and appearance self‐esteem, cognitive functioning and salivary cortisol. Results Participants who had experienced frequent weight discrimination in the past were more likely to attribute the negative evaluation to their appearance. Participants who attributed the negative evaluation to their appearance in turn experienced elevated negative affect, lower appearance self‐esteem and worse cognitive functioning. Conclusions This study is among the first to identify attribution as an early‐stage process underlying responses to weight stigma. Attribution may be a key psychological factor conferring risk for or protection from the negative effects of weight stigma.
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Affiliation(s)
- Mary A Gerend
- Department of Behavioral Sciences and Social Medicine, College of Medicine Florida State University Tallahassee Florida USA
| | - Angelina R Sutin
- Department of Behavioral Sciences and Social Medicine, College of Medicine Florida State University Tallahassee Florida USA
| | - Antonio Terracciano
- Department of Geriatrics, College of Medicine Florida State University Tallahassee Florida USA
| | - Jon K Maner
- Department of Psychology, College of Arts and Sciences Florida State University Tallahassee Florida USA
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Abstract
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.
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Affiliation(s)
| | | | - Joshua Smyth
- Department of Biobehavioral Health, The Pennsylvania State University, USA
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21
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Suvarna B, Suvarna A, Phillips R, Juster R, Mcdermott B, Sarnyai Z. Health risk behaviours and allostatic load: A systematic review. Neurosci Biobehav Rev 2020; 108:694-711. [DOI: 10.1016/j.neubiorev.2019.12.020] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 12/05/2019] [Accepted: 12/11/2019] [Indexed: 12/26/2022]
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Olesen K, Cleal B, Willaing I. Discrimination and stigma among people with type 2 diabetes in the workplace: prejudice against illness or obesity? Public Health 2019; 180:100-101. [PMID: 31881462 DOI: 10.1016/j.puhe.2019.11.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 11/08/2019] [Accepted: 11/12/2019] [Indexed: 11/18/2022]
Abstract
OBJECTIVES Both obesity/overweight and type 2 diabetes (T2D) have been independently identified as being the basis for stigma and discrimination in the workplace. The study sought to test the hypothesis that people with T2D are at increased risk of discrimination and adverse self-reported psychosocial work environment. STUDY DESIGN This study was based on survey data from 2415 working Danes with T2D (n = 586) and without T2D (n = 1829) recruited from online panels. Single self-reported items were used to obtain information about diabetes status, exposure to discrimination and other individual factors. METHODS Descriptive statistics and linear regression were used for the data analysis. RESULTS Six percent of the participants with T2D had experienced some type of discrimination at work, which was ascribed to their diabetes. People with diabetes had higher levels of effort-reward imbalance. When adjusting for body mass index, differences in relation to effort-reward imbalance were accounted for. CONCLUSIONS People with T2D reported relatively poor psychosocial working environment compared with the general working population, but the difference was removed by adjusting for overweight/obesity. This indicates that T2D alone is not a source of stigma and discrimination in the context of work. Levels of perceived discrimination were notably lower than expected among people with diabetes as a whole, but a number of people, nonetheless, continue to be exposed to the destructive effects of discrimination in the context of work.
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Affiliation(s)
- K Olesen
- Steno Diabetes Center Copenhagen, Denmark.
| | - B Cleal
- Steno Diabetes Center Copenhagen, Denmark
| | - I Willaing
- Steno Diabetes Center Copenhagen, Denmark
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Potter L, Zawadzki MJ, Eccleston CP, Cook JE, Snipes SA, Sliwinski MJ, Smyth JM. The Intersections of Race, Gender, Age, and Socioeconomic Status: Implications for Reporting Discrimination and Attributions to Discrimination. Stigma Health 2019; 4:264-281. [PMID: 31517056 PMCID: PMC6741774 DOI: 10.1037/sah0000099] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
This study employed an intersectional approach (operationalized as the combination of more than one social identity) to examine the relationship between aspects of social identity (i.e., race, gender, age, SES), self-reported level of mistreatment, and attributions for discrimination. Self-reported discrimination has been researched extensively and there is substantial evidence of its association with adverse physical and psychological health outcomes. Few studies, however, have examined the relationship of multiple demographic variables (including social identities) to overall levels self-reported mistreatment as well the selection of attributions for discrimination. A diverse community sample (N = 292; 42.12% Black; 47.26% male) reported on experiences of discrimination using the Everyday Discrimination Scale. General linear models were used to test the effect of sociodemographic characteristics (i.e., race, gender, age, SES) on total discrimination score and on attributions for discrimination. To test for intersectional relationships, we tested the effect of two-way interactions of sociodemographic characteristics on total discrimination score and attributions for discrimination. We found preliminary support for intersectional effects, as indicated by a significant race by age interaction on the selection of the race attribution for discrimination; gender by SES on the age attribution; age by gender on the education attribution; and race by SES on the economic situation attribution. Our study extends prior work by highlighting the importance of testing more than one factor as contributing to discrimination, particularly when examining to what sources individuals attribute discrimination.
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Daly M, Sutin AR, Robinson E. Perceived Weight Discrimination Mediates the Prospective Association Between Obesity and Physiological Dysregulation: Evidence From a Population-Based Cohort. Psychol Sci 2019; 30:1030-1039. [PMID: 31158067 DOI: 10.1177/0956797619849440] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Obesity is thought to cause ill health because of the biological strain that excess fat has on physiological function. We tested an alternative explanation in a population-based sample of 3,609 older English adults-that the pervasive discrimination experienced by individuals with excess weight may in part explain why obesity is associated with subsequent multisystem physiological dysregulation, measured via clinical indicators of cardiovascular, metabolic, and immune function. We found that both obesity and perceived weight discrimination predicted an increase in physiological dysregulation from baseline to follow-up 4 years later. Perceived discrimination because of body weight experienced by individuals with obesity explained more than one quarter of the prospective association between obesity and a deterioration in biomarkers of health status. These findings highlight the possibility that the stigma experienced by individuals with obesity may play an important role in explaining the obesity-related disease burden.
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Affiliation(s)
- Michael Daly
- 1 Department of Psychology, Maynooth University.,2 UCD Geary Institute for Public Policy, University College Dublin
| | - Angelina R Sutin
- 3 Department of Behavioral Sciences and Social Medicine, Florida State University College of Medicine
| | - Eric Robinson
- 4 Department of Psychological Sciences, Institute of Population Health Sciences, University of Liverpool
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Eisenberg D, Noria S, Grover B, Goodpaster K, Rogers AM. ASMBS position statement on weight bias and stigma. Surg Obes Relat Dis 2019; 15:814-821. [DOI: 10.1016/j.soard.2019.04.031] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 04/27/2019] [Indexed: 12/14/2022]
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Shank LM, Schvey NA, Ekundayo K, Schreiber-Gregory D, Bates D, Maurer D, Spieker E, Stephens M, Tanofsky-Kraff M, Sbrocco T. The relationship between weight stigma, weight bias internalization, and physical health in military personnel with or at high-risk of overweight/obesity. Body Image 2019; 28:25-33. [PMID: 30481680 DOI: 10.1016/j.bodyim.2018.11.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 11/17/2018] [Accepted: 11/17/2018] [Indexed: 12/20/2022]
Abstract
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.
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Affiliation(s)
- Lisa M Shank
- Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences (USUHS), DoD, 4301 Jones Bridge Road, Bethesda, MD, 20814, USA; The Henry M. Jackson Foundation for the Advancement of Military Medicine (HJF), 6720A Rockledge Drive #100, Bethesda, MD, 20817, USA.
| | - Natasha A Schvey
- Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences (USUHS), DoD, 4301 Jones Bridge Road, Bethesda, MD, 20814, USA
| | - Kendra Ekundayo
- Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences (USUHS), DoD, 4301 Jones Bridge Road, Bethesda, MD, 20814, USA; The Henry M. Jackson Foundation for the Advancement of Military Medicine (HJF), 6720A Rockledge Drive #100, Bethesda, MD, 20817, USA
| | - Deanna Schreiber-Gregory
- The Henry M. Jackson Foundation for the Advancement of Military Medicine (HJF), 6720A Rockledge Drive #100, Bethesda, MD, 20817, USA; Department of Internal Medicine, USUHS, DoD, 4301 Jones Bridge Road, Bethesda, MD, 20814, USA
| | - Dawn Bates
- Madigan Army Medical Center, 9040 Jackson Ave, Tacoma, WA, 98431, USA
| | - Douglas Maurer
- Madigan Army Medical Center, 9040 Jackson Ave, Tacoma, WA, 98431, USA
| | - Elena Spieker
- Madigan Army Medical Center, 9040 Jackson Ave, Tacoma, WA, 98431, USA
| | - Mark Stephens
- Department of Family and Community Medicine, Penn State University College of Medicine, 1850 E. Park Avenue, Suite 207 State College, PA, 16803, USA
| | - Marian Tanofsky-Kraff
- Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences (USUHS), DoD, 4301 Jones Bridge Road, Bethesda, MD, 20814, USA
| | - Tracy Sbrocco
- Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences (USUHS), DoD, 4301 Jones Bridge Road, Bethesda, MD, 20814, USA
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Bogusch LM, O'Brien WH. The Effects of Mindfulness-Based Interventions on Diabetes-Related Distress, Quality of Life, and Metabolic Control Among Persons with Diabetes: A Meta-Analytic Review. Behav Med 2019; 45:19-29. [PMID: 29617221 DOI: 10.1080/08964289.2018.1432549] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Mindfulness-based interventions (MBIs) have improved psychological outcomes for multiple chronic health conditions, including diabetes. A meta-analytic review of the literature was conducted on all located studies (n = 14) investigating MBIs that targeted diabetes-related distress (DRD) and diabetes-related outcomes among people with Type 1 and Type 2 diabetes. PsychInfo, PubMed, Medline, and Web of Science were searched for MBIs that were designed to improve DRD and other secondary outcomes, including quality of life and measures of metabolic control. A meta-analysis of these outcomes uncovered small-to-moderate effect sizes for intervention studies measuring pretreatment to posttreatment changes in DRD and metabolic control among treatment group participants. However, the pretreatment to follow-up comparisons for DRD and metabolic control were small and unreliable. For control groups, all pre-treatment to post-treatment and pre-treatment to follow-up comparisons were unreliable for all outcomes. A moderate effect size for treatment-control comparisons was found for intervention studies measuring quality of life outcomes at posttreatment, but not at follow-up comparisons. All other effect sizes for treatment-control comparisons were unreliable. Limitations and implications for MBIs among individuals with diabetes are discussed.
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Affiliation(s)
- Leah M Bogusch
- a Psychology Department , Bowling Green State University
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Bombak AE, Riediger ND, Bensley J, Ankomah S, Mudryj A. A systematic search and critical thematic, narrative review of lifestyle interventions for the prevention and management of diabetes. Critical Public Health 2018. [DOI: 10.1080/09581596.2018.1516033] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- Andrea E. Bombak
- Department of Sociology, University of New Brunswick, Fredericton, Canada
- School of Health Sciences, Central Michigan University, Mt Pleasant, MI, USA
| | - Natalie D. Riediger
- Department of Food and Human Nutritional Sciences, Faculty of Agricultural and Food Sciences, University of Manitoba, Winnipeg, Canada
- Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Jackson Bensley
- School of Health Sciences, Central Michigan University, Mt Pleasant, MI, USA
| | - Samuel Ankomah
- School of Health Sciences, Central Michigan University, Mt Pleasant, MI, USA
| | - Adriana Mudryj
- Department of Food and Human Nutritional Sciences, Faculty of Agricultural and Food Sciences, University of Manitoba, Winnipeg, Canada
- Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
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Valdez RS, Guterbock TM, Fitzgibbon K, Williams IC, Wellbeloved-Stone CA, Bears JE, Menefee HK. From loquacious to reticent: understanding patient health information communication to guide consumer health IT design. J Am Med Inform Assoc 2018; 24:680-696. [PMID: 28069667 DOI: 10.1093/jamia/ocw155] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Background and significance It is increasingly recognized that some patients self-manage in the context of social networks rather than alone. Consumer health information technology (IT) designed to support socially embedded self-management must be responsive to patients' everyday communication practices. There is an opportunity to improve consumer health IT design by explicating how patients currently leverage social media to support health information communication. Objective The objective of this study was to determine types of health information communication patterns that typify Facebook users with chronic health conditions to guide consumer health IT design. Materials and methods Seven hundred participants with type 2 diabetes were recruited through a commercial survey access panel. Cluster analysis was used to identify distinct approaches to health information communication both on and off Facebook. Analysis of variance (ANOVA) methods were used to identify demographic and behavioral differences among profiles. Secondary analysis of qualitative interviews ( n = 25) and analysis of open-ended survey questions were conducted to understand participant rationales for each profile. Results Our analysis yielded 7 distinct health information communication profiles. Five of 7 profiles had consistent patterns both on and off Facebook, while the remaining 2 demonstrated distinct practices, with no health information communication on Facebook but some off Facebook. One profile was distinct from all others in both health information communication practices and demographic composition. Rationales for following specific health information communication practices were categorized under 6 themes: altruism, instrumental support, social support, privacy and stigma, convenience, and Facebook knowledge. Conclusion Facebook has been widely adopted for health information communication; This study demonstrates that Facebook has been widely adopted for health information communication. It also shows that the ways in which patients communicate health information on and off Facebook are diverse.
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Affiliation(s)
- Rupa S Valdez
- Center for Survey Research, Department of Sociology, University of Virginia, Charlottesville, VA, USA
| | - Thomas M Guterbock
- Center for Survey Research, Department of Sociology, University of Virginia, Charlottesville, VA, USA
| | - Kara Fitzgibbon
- Center for Survey Research, Department of Sociology, University of Virginia, Charlottesville, VA, USA
| | - Ishan C Williams
- School of Nursing, University of Virginia, Charlottesville, VA, USA
| | | | - Jaime E Bears
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA
| | - Hannah K Menefee
- Department of Population Health Sciences, Virginia Polytechnic Institute and State University, Blacksburg, VA, USA
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Lebrón AMW, Spencer M, Kieffer E, Sinco B, Palmisano G. Racial/Ethnic Discrimination and Diabetes-Related Outcomes Among Latinos with Type 2 Diabetes. J Immigr Minor Health 2019; 21:105-14. [DOI: 10.1007/s10903-018-0710-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Abstract
BACKGROUND Discrimination promotes multisystem physiological dysregulation termed allostatic load, which predicts morbidity and mortality. It remains unclear whether weight-related discrimination influences allostatic load. PURPOSE The aim of this study was to prospectively examine 10-year associations between weight discrimination, allostatic load, and its components among adults 25-75 years in the Midlife Development in the US Biomarker Substudy. METHODS Participants with information on weight discrimination were analyzed (n=986). At both timepoints, participants self-reported the frequency of perceived weight discrimination across nine scenarios as "never/rarely" (scored as 0), "sometimes" (1), or "often" (2). The two scores were averaged and then dichotomized as "experienced" versus "not experienced" discrimination. High allostatic load was defined as having ≥3 out of 7 dysregulated systems (cardiovascular, sympathetic/parasympathetic nervous systems, hypothalamic pituitary axis, inflammatory, lipid/metabolic, and glucose metabolism), which collectively included 24 biomarkers. Relative risks (RR) were estimated from multivariate models adjusted for sociodemographic and health characteristics, other forms of discrimination, and BMI. RESULTS Over 41% of the sample had obesity, and 6% reported weight discrimination at follow-up. In multivariable-adjusted analyses, individuals who experienced (versus did not experience) weight discrimination had twice the risk of high allostatic load (RR, 2.07; 95 % CI, 1.21; 3.55 for baseline discrimination; 2.16, 95 % CI, 1.39; 3.36 for long-term discrimination). Weight discrimination was associated with lipid/metabolic dysregulation (1.56; 95 % CI 1.02, 2.40), glucose metabolism (1.99; 95 % CI 1.34, 2.95), and inflammation (1.76; 95 % CI 1.22, 2.54), but no other systems. CONCLUSIONS Perceived weight discrimination doubles the 10-year risk of high allostatic load. Eliminating weight stigma may reduce physiological dysregulation, improving obesity-related morbidity and mortality.
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Affiliation(s)
- Maya Vadiveloo
- Department of Nutrition and Food Sciences, University of Rhode Island, Kingston, RI, 02881, USA
| | - Josiemer Mattei
- Department of Nutrition, Harvard T. H. Chan School of Public Health, 665 Huntington Ave, Bldg 2, Boston, MA, 02115, USA.
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Abstract
The bulk of the literature on the relationship of discrimination to health has relied on retrospective reports of perceived exposure to discrimination. Much less is known known about the real-time within-person association between discrimination and biopsychosocial processes. Intensive longitudinal methods, including ecological momentary assessment (EMA) and daily diary studies, are well suited for studying the dynamic nature of discriminatory experiences in daily life. This review examines research utilizing EMA and daily diaries to study discrimination within individuals in real-time and natural settings. We identified studies of discrimination related to race, sex, weight, and sexual orientation, and examined the prevalence and frequency of discrimination in daily life, the psychosocial correlates of discrimination, contextual factors related to discriminatory experiences, and moderators of the effects of discrimination. We highlight the benefits of using EMA and daily diaries in the study of discrimination and biopsychosocial processes, and provide suggestions for future work on these associations. EMA data suggests that discrimination occurs more frequently than might be clear from survey research and is associated with poor mental health in daily life. Further, discrimination may be enacted through various means (e.g., verbal expressions, behavior), by a variety of perpetrators (e.g., spouses, friends), and in various settings (e.g., in the home, in public places) in daily life. This methodology has potential to facilitate our understanding of the dynamic temporal relationship between cognitive, behavioral, and emotional responses to discrimination and poor health outcomes in daily life.
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Pearl RL, Wadden TA, Hopkins CM, Shaw JA, Hayes MR, Bakizada ZM, Alfaris N, Chao AM, Pinkasavage E, Berkowitz RI, Alamuddin N. Association between weight bias internalization and metabolic syndrome among treatment-seeking individuals with obesity. Obesity (Silver Spring) 2017; 25:317-322. [PMID: 28124502 PMCID: PMC5300503 DOI: 10.1002/oby.21716] [Citation(s) in RCA: 87] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Revised: 10/14/2016] [Accepted: 10/17/2016] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Weight stigma is a chronic stressor that may increase cardiometabolic risk. Some individuals with obesity self-stigmatize (i.e., weight bias internalization, WBI). No study to date has examined whether WBI is associated with metabolic syndrome. METHODS Blood pressure, waist circumference, and fasting glucose, triglycerides, and high-density lipoprotein cholesterol were measured at baseline in 178 adults with obesity enrolled in a weight-loss trial. Medication use for hypertension, dyslipidemia, and prediabetes was included in criteria for metabolic syndrome. One hundred fifty-nine participants (88.1% female, 67.3% black, mean BMI = 41.1 kg/m2 ) completed the Weight Bias Internalization Scale and Patient Health Questionnaire (PHQ-9, to assess depressive symptoms). Odds ratios and partial correlations were calculated adjusting for demographics, BMI, and PHQ-9 scores. RESULTS Fifty-one participants (32.1%) met criteria for metabolic syndrome. Odds of meeting criteria for metabolic syndrome were greater among participants with higher WBI, but not when controlling for all covariates (OR = 1.46, 95% CI = 1.00-2.13, P = 0.052). Higher WBI predicted greater odds of having high triglycerides (OR = 1.88, 95% CI = 1.14-3.09, P = 0.043). Analyzed categorically, high (vs. low) WBI predicted greater odds of metabolic syndrome and high triglycerides (Ps < 0.05). CONCLUSIONS Individuals with obesity who self-stigmatize may have heightened cardiometabolic risk. Biological and behavioral pathways linking WBI and metabolic syndrome require further exploration.
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Affiliation(s)
- Rebecca L. Pearl
- Center for Weight and Eating Disorders, Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania
- Corresponding Author: Rebecca L. Pearl, 3535 Market Street, Suite 3026, Philadelphia, PA 19104,
| | - Thomas A. Wadden
- Center for Weight and Eating Disorders, Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania
| | - Christina M. Hopkins
- Center for Weight and Eating Disorders, Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania
| | - Jena A. Shaw
- Center for Weight and Eating Disorders, Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania
| | - Matthew R. Hayes
- Center for Weight and Eating Disorders, Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania
- Department of Biobehavioral Health Sciences, School of Nursing, University of Pennsylvania
| | - Zayna M. Bakizada
- Center for Weight and Eating Disorders, Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania
| | - Nasreen Alfaris
- MGH Weight Center, Department of Medicine Gastrointestinal Unit, Massachusetts General Hospital, Boston, MA
| | - Ariana M. Chao
- Center for Weight and Eating Disorders, Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania
- Department of Family and Community Health, School of Nursing, University of Pennsylvania
| | - Emilie Pinkasavage
- Center for Weight and Eating Disorders, Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania
| | - Robert I. Berkowitz
- Center for Weight and Eating Disorders, Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania
- Department of Psychiatry and Behavioral Sciences, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Naji Alamuddin
- Center for Weight and Eating Disorders, Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania
- Institute for Diabetes, Obesity, and Metabolism, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania
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Sutin AR, Stephan Y, Grzywacz JG, Robinson E, Daly M, Terracciano A. Perceived weight discrimination, changes in health, and daily stressors. Obesity (Silver Spring) 2016; 24:2202-9. [PMID: 27581053 PMCID: PMC5301307 DOI: 10.1002/oby.21598] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Revised: 06/04/2016] [Accepted: 06/07/2016] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To examine whether perceived weight discrimination is associated with change in health markers over time and whether it is associated with daily stressors, physical symptoms, and affect. METHODS Participants were selected from the Midlife in the United States (MIDUS) study if they had data on perceived weight discrimination and health markers at MIDUS II (2004-2006), health markers at MIDUS III (2013-2014), and a body mass index ≥25 kg/m(2) (N = 1,841). A subset of these participants (N = 1,153) reported on their experiences daily for 8 days as part of the second National Study of Daily Experiences. RESULTS Perceived weight discrimination was associated with declines in mental and physical health over time (median β = 0.06). Participants who reported weight discrimination experienced more daily stressors (β = 0.13), physical symptoms (β = 0.13), and negative affect (β = 0.13) and less positive affect (β = -0.12) over the 8 days of the second National Study of Daily Experiences. Weight discrimination was most strongly associated with interpersonal stressors (median β = 0.14), feelings of anger (β = 0.16) and frustration (β = 0.14), lower attention (β = -0.14) and activity (β = -0.16), and more nonspecific physical symptoms (e.g., fatigue; β = 0.10). CONCLUSIONS This research replicates the association between perceived weight discrimination and worse health over time and extends this literature to show that people who experience weight discrimination have more daily stressors, physical symptoms, and negative emotions.
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Affiliation(s)
- Angelina R Sutin
- Department of Behavioral Sciences and Social Medicine, Florida State University College of Medicine, Tallahassee, Florida, USA.
| | - Yannick Stephan
- Laboratory of Dynamic of Human Abilities and Health Behaviors, University of Montpellier, Montpellier, France
| | - Joseph G Grzywacz
- Department of Family and Child Sciences, Florida State University College of Human Sciences, Tallahassee, Florida, USA
| | - Eric Robinson
- Department of Psychological Sciences, Institute of Psychology, Health & Society, University of Liverpool, Liverpool, Merseyside, UK
| | - Michael Daly
- Behavioural Science Centre, University of Stirling, Scotland, UK
- Behavioural Science Centre, UCD Geary Institute, University College Dublin, Dublin, Ireland
| | - Antonio Terracciano
- Department of Geriatrics, Florida State University College of Medicine, Tallahassee, Florida, USA
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