Understanding Obesity Stigma as a Stressor Across the lifecourse - PowerPoint Presentation

Understanding Obesity Stigma as a Stressor Across the lifecourse Sharon Bernecki DeJoy, PhD, MPH, CPH, CPM West Chester University of Pennsylvania

Acknowledgments With thanks to: UConn Rudd Center for Food Policy and Obesity Janell M ensinger, PhD Drexel University College of Nursing and Health Professions Emily Holladay West Chester University of Pennsylvania BS Public Health-Health Promotion student Debra M andel, PhD, RNC-OB West Chester University of Pennsylvania College of Health Sciences Krystle Bittner, MPH

Obesity in Pregnancy

Epidemiology P revalence of pre-pregnancy overweight in women: 24.9% P revalence of pre-pregnancy obesity: 22.1% 2009 PRAMS data (Robbins et al., 2014 )

Maternal Complications of Obesity Miscarriage Hypertensive disorders Gestational Diabetes Mellitus (GDM) Preterm Birth Assisted Vaginal Delivery Stillbirth Cesarean delivery Wound infection Postpartum hemorrhage Anesthetic complicationsIncreased length of stay in hospital Galliano & B ellver, 2013

Fetal Complications Congenital Anomalies Fetal Distress Macrosomy Hydramnios Shoulder Dystocia Hypoglycemia J aundice Galliano & B ellver, 2013

Postnatal Complications Obesity Type 2 Diabetes Cancer Neurodevelopmental delay Galliano & B ellver, 2013

Effectiveness of interventions in pregnancy Behavioral interventions reduced gestational weight gain by 3.6 pounds, on average, among women with obesity, but not among overweight or severely obese women. These interventions had no effect on length of gestation or infant birth weight, and did not affect the woman’s postpartum weight status in any weight category. Postpartum/interconceptional weight loss is possible, but best practices are emerging. Agha, Agha & S andell, 2014; Nascimento et al., 2014; van der Pligt et al, 2013

Effectiveness of Weight Loss Interventions in general Weight loss of 5% to 10% = success Only 10-20% can maintain a 10% a weight loss after 1 year 10% loss is typical outcome of the best behavioral and/or pharmacological treatments Significant weight loss is not readily sustainable with current conventional treatment options Wadden & Foster, 2000; Wing & Hill, 2001

Maternal obesity is a public health problem. Why is it addressed through less-than-effective individual-level interventions?

Theoretical Frameworks in MCH Lifecourse Framework, Social Ecological Model, and Multiple Determinants

Life Course perspective-Key Concepts “ Today’s experiences and exposures influence tomorrow’s health. (Timeline) Health trajectories are particularly affected during critical or sensitive periods. (Timing) The broader community environment – biologic, physical, and social – strongly affects the capacity to be healthy. (Environment) While genetic make-up offers both protective and risk factors for disease conditions, inequality in health reflects more than genetics and personal choice. (Equity)” U.S . Department of Health and Human Services, 2010, p. 4

Social Ecological model Source: CDC

Figure 1 Women’s reproductive cycles. Source: Misra, Guyer & Allston, (2003)

Social determinant: Racism C onsistent associations between perceptions of racial discrimination and preterm birth, low birth weight, and very low birth weight in African-American women . ( Earnshaw et al., 2013; Giurgescu, McFarlin, Lomax, Craddock, & Albrecht, 2011) Structural racism places African-American populations at elevated risk for social and economic disadvantage. (Mendez, Hogan, & Culhane, 2014).Interpersonal racism in daily life and health care encounters can provoke psychosocial distress. (Williams, Yu, Jackson, & Anderson, 1997)

Obesity Stigma as a social determinant of health

What is stigma? Convergence of 5 processes Labeling of human differences occurs Individual is linked to undesirable characteristics (stereotyped) Separation of stigmatized others (“us” versus “them”) Discrimination and loss of status occurs Power differences Link & Phelan, 2001

19 Source: Puhl , R.M. (2013) Clinical Implications of Obesity . Presentation, Rudd Center for Food Policy and Obesity.

Obesity Stigma : A widespread problem Research shows overt weight-based discrimination has increased among children and adults Children report weight as most common reason for bullying One study showed that 92.5% of undergraduate sample endorsed fat stigma Family members followed by physicians are most common source of weight stigmatization Ambwani et al, 2014; Andreyeva , et al., 2008. Puhl &Brownell , 2006; Puhl et al., 2011

Weight stigma in employment People with a higher BMI are… Less likely to be interviewed Less likely to be hired Earn less Fewer promotions Employers rate larger people as Less competent, lazy, sloppy, disagreeable, emotionally unstable Puhl & Peterson, 2014

Weight stigma in education Children with a higher BMI perform poorer academically Research shows weight-based teasing may play a mediating role Children report missing school due to weight-based victimization Teachers have lower expectations of children with a high BMI Larger sized children are characterized by teachers as: Untidy Emotional Less likely to succeed at work More like to have family problems Krukowski , et al., 2009; Neumark-Sztainer, Story, & Harris, 1999; Puhl, Luedicke, & Heuer, 2011

Weight bias in health care

Weight Bias is prevalent across professional groups Studies documented weight bias in : Physicians Nurses Medical students Psychologists Dietitians Fitness professionalsPuhl & Brownell, 2001; Puhl & Heuer, 2009

Perceptions of clients with obesity Providers view obese patients as Non compliant Lazy Awkward Weak-willed Dishonest Unsuccessful Unintelligent Ferrante et al., 2009; Campbell et al., 2000; Fogelman et al., 2002; Foster, 2003; Hebl & Xu, 2001; Puhl & Heuer, 2009; Huizinga et al., 2010

Weight Bias Physicians report As patient BMI increases, physicians report : having less patience less desire to help the patient seeing obese patients was a waste of their time having less respect for patientsHebl & Xu, 2001; Huizinga et al., 2009

Weight Bias Nurses report: 31% “would prefer not to care for obese patients” 12% “would prefer not to touch obese patients” 24% agreed that obese patients “repulsed them” Poon & Tarrant, 2009; Brown, 2006; Bagley, 1989; Hoppe & Ogden, 1997; Maroney & Golub, 1992

Patient Reactions Feel berated & disrespected by providers Report that their weight is blamed for all problems Upset by comments about their weight from doctors Reluctant to address weight concerns Perceive that they will not be taken seriouslyAnderson & Wadden, 2004; Bertakis & Azari, 2005; Brown et al., 2006; Edmunds, 2005

Is Care Affected? Provider interactions with obese patients Less time spent in appointments Less discussion with patients More assignment of negative symptoms Less intervention Bacquier et al., 2005; Bertakis & Azari, 2005; Campbell et al., 2000; Galuska et al., 1999; Hebl & Xu, 2001; Kristeller & Hoerr, 1997

Impact on Care Patients with obesity are less likely to obtain… Preventive health services & exams Cancer screens, pelvic exams, mammograms and are more likely to… Cancel appointments Delay appointments and preventive care service Adams et al., 1993; Aldrich & Hackley, 2010; Drury & Louis, 2002; Fontaine et al., 1998; Olson et al., 1994, Ostbye et al., 2005; Wee et al., 2000

Avoidance of Care Study of 498 women: Obese women delayed preventive services despite high access Women attributed their decisions to: Disrespect from providers Embarrassment of being weighed Negative provider attitudes Medical equipment too small *Barriers increased with BMI Amy et al. ( 2006 )

How stigma “gets under the skin” What are the health consequences of all this? 32

allostatic load Multi-disciplinary , framework for studying the relationship between stress and disease Operationalized as a index of physiological dysregulation involving multiple organ systems C aptures how our body copes with threatening or unpredictable environmental stimuli Is the consequence of regulatory “wear and tear” on the body and brain that leads to illness33 McEwen, B. S., & Stellar, E. (1993).

Allostatic Load Chemical messengers released in brain in response to stress Chronic or frequent demands for these messengers can lead to insufficient, non-habituating, or prolonged production Metabolic , inflammatory, and cardiovascular systems all become dysregulated

35 Beckie, (2012)

Perceived discrimination and health 2009 Meta-analysis shows very robust associations Data from 110 studies examining mental health Symptoms of depression, anxiety, PTSD, psychosis, paranoia, psychological distress, general well-being, life satisfaction, self-esteem, perceived stress, anger, etc.) Data from 36 studies examining physical health Outcomes included BP, plaque, heart rate variability, CVD, pelvic inflammatory disease, yeast infections, respiratory conditions, etc. 36 Pascoe & Smart Richman, (2009)

Weight stigma and mental health Depression Anxiety Disordered eating Self-esteem Exercise Avoidance 37 Durso et al., ( 2012); Greenleaf , Petrie , & Martin, (2014); Hilbert , Braehler , Haeuser , & Zenger ,(2014)

Weight/physical appearance discrimination and ambulatory BP Sample of 207 Black and White adolescents Rating physical appearance/weight as being the primary reason for being discriminated against was a predictor of higher ambulatory blood pressure after controlling for BMI, race, sex, physical activity Race was also a predictor of BP 38 Matthews, Salomon , Kenyon , & Zhou (2005)

Perceived Weight stigma and HPA activation Weight stigma frequency and stress hormones measured in 45 women with high BMI Models controlled for abdominal adiposity, perceived stress, age, income, education Significant associations between weight stigma and stress hormones regardless of weight status 39 Tomiyama, Epel, McClatchey , et al. (2014 )

Obesity Stigma and Health behavior

Health Consequences Maladaptive eating behaviors Binge eating, unhealthy weight control practices, comping with stigma my eating more food Study: Survey of 2,449 women How do they cope with stigma experiences? 79% reported eating; turning to food as coping mechanism Haines, et al., 2006; Neumark-Sztainer et al., 2002; Puhl & Brownell, 2006, Puhl et al., 2007; Puhl & Luedicke, 2011

Health Consequences Internalizing Weight Stigma Study: 1013 women (national non-profit weight loss support organization) Women who internalized experiences of weight stigma and blamed themselves engaged in more frequent binge eating (even after accounting for self-esteem, depression, and amount of stigma experienced) Puhl, Moss-Racusin, Schwartz, (2007 )

Behavioral consequences of obesity stigma Higher calorie intake Higher program attrition Less weight loss Avoidance of physical activity Lower motivation for exercise Bauer et al., 2004; Faith et al, 2002; Matthews et al., 2005; Schwimmer et al., 2003, Storch et al., 2006; Schmaltz, 2010; Seacat & Mickelson 2009; Vartanian & Shaprow, 2008; Vartanian & Novak, 2011

Source: Puhl & Heuer, (2010) In sum…does a high BMI or the stress of being stigmatized for it cause disease?

Obesity Stigma in Pregnancy Upstream and downstream determinant of Poor Birth Outcomes?

Social Determinants Root Causes

Studies of Weight Stigma and Pregnancy Little research conducted on chronic or recent obesity stigma experienced by pregnant women with a high BMI Given the rates of obesity stigma and associated pregnancy complications in the U.S. it is critical to examine this issue DeJoy & Bittner (2015 )

“Size-ism” as structural disadvantage/Downstream influence Intersection of weight and gender discrimination is major source of inequity in the US . (Mason, 2012). Overweight and obese individuals are at increased risk of employer discrimination. (Puhl & Heuer, 2011; Puhl , Heuer, & Brownell, 2010) Obese women tend to have lower levels of educational attainment and income and a lower marriage rate than their thinner peers. (Puhl & Heuer, 2010)

International Studies of Weight Stigma and Pregnancy From Scandinavia, Australia and the UK Depersonalization Medicalization Lack of respect Smith & Lavender(2011 )

U.S. Study on Experiences of Weight Stigma in Maternity Care DeJoy, Bittner , & Mandel (2015 ).

Selected Quotes I basically got a lecture every time I went in. They made judgments about what I ate, about how much I exercised. They never asked me; they just said things like “don’t drink soda,” which I don’t, and “don’t eat candy bars,” which I don’t. They kept saying the baby was going to be super large and you’ll never be able to deliver vaginally because he’ll be so big – and he wasn’t; he was a perfectly normal 7lbs, 6oz. I had one doctor who came to see me in the hospital …I was eating a small snack-size bag of cookies and he walked in and just totally scoffed at me that I was eating cookies. He said, “It’s things like that, I have to tell you… I can’t even prescribe you birth control, because you’re too fat for birth control pills.” I was not pre-eclamptic, I wasn’t diabetic, I wasn’t having any additional problems, I had no complications. I was just “fat while pregnant” and therefore needed a c-section.

Weight Stigma: A Source of unnecessary interventions? Higher risk of cesarean delivery attributable to labor management, not BMI. (Abenhaim & Benjamin, 2011)

Obesity Stigma as a Social Determinant of Disparities in Birth Outcomes

Research Questions/Gaps in the Literature How do women with obesity experience stigma over the lifecourse? Does pregnancy exacerbate or alleviate stigma? Is stigma associated with poorer mental health during pregnancy? If so, what coping behaviors are used and are they healthful or not? Does stress manifest in biological markers in pregnancy? Do women who experience more stigma or more distress due to stigma have poorer birth outcomes? How does the experience of stigma vary by race/ethnicity and other sociodemographic variables? How much of the variation in the medicalization of obesity in pregnancy can be explained by physiology versus provider bias?

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