DYNAMIC ASSESSMENT OF OBESITY STIGMATIZATION

Jason D. Seacat, Ph.D.

Department of Psychology, Western New England University

Overview

Part 1: Obesity Overview Define and discuss obesity and trends in US Obesity stigmatization Consequences of obesity stigmatization

Part 2: Assessment of Stigmatization Daily diary assessment of stigmatization

Preliminary research findings Laboratory assessment of stigmatization

effects Triangulating assessment strategies

Part I: Operational Definitions Operational Definitions (CDC Body Mass

Index) Overweight ≥ 25 Obesity ≥ 30 Morbid Obesity ≥ 40-44.9 Super Morbid Obesity ≥ 45

Assessment of Obesity Status BMI Body Fat % Scales (e.g., Tanita) Skin fold thickness Bioelectric impedance assay

Obesity Trends-Adults

Prevalence of Overweight/Obese in the United States Despite increasing awareness, education

and intervention the obesity epidemic continues to intensify

36% of adults are overweight 34% of adults are obese (Flegal et al.,

2008)

U.S. Trends and Projections

National Health and Nutrition Survey

U.S. Disparities

Racial/Ethnic Disparity of Obesity Non-Hispanic Black- 44% Mexican American- 39.3% All Hispanic- 37.9% Caucasian- 32.6%

Geographic Disparity South- 29.4% Midwest- 28.7% Northeast- 24.9% West- 24.1%CDC, 2011

Consequences of Obesity

Physical Health Consequences Coronary Heart Disease/Stroke Type II Diabetes Hypertension Certain Cancers (e.g., endometrial,colorectal) Osteoarthritis

Economic Consequences Medical costs alone associated with obesity

$147 Billion (Finkelstein, 2009)

Consequences of Obesity

Social Consequences Obesity stigmatization

According to Puhl and Heuer (2009), obesity “remains one of the last acceptable targets of stigma/discrimination”

Despite increasing rates of obesity, obesity stigmatization is also increasing

Obesity Stigmatization

Rates of obesity stigmatization have increased by 66% since 1995 (Schvey, Puhl & Brownell, 2011)

More than 70% of overweight/obese individuals now report frequent stigmatization

Obesity stigmatization occurs in ALL life domains While both sexes encounter weight stigma,

women are more frequently targeted than men Women may also be more susceptible to negative

consequences of stigma due to gender-based attractiveness norms

Types of Obesity Stigma

Direct- (Institutional & Interpersonal) (e.g., bullying, denial of housing, workplace harassment, relationship abuse, ostracizing of obese individuals)

Indirect- (Perceived) Individual perceptions of stigma and/or internalization of stigma Indirect stigma may actually be more

potent than direct as it operates independently of actual occurrences

Researchers need to assess both direct and indirect forms of stigmatization

Consequences of Obesity Stigma Though consequences of stigma are

individualized there are several commonly reported outcomes, including: Lack of access/opportunity Psychological/emotional trauma Social isolation Delay/avoidance of medical treatment Avoidance of healthy behaviors (e.g., exercise,

compensatory eating) (Seacat & Mickelson, 2009; Vartanian & Colleagues, 2011)

Perpetuation and exacerbation of obesity status**

Assessing Obesity Stigmatization

Existing stigma studies indicate that experiences with obesity stigma range from a low of 1 time per month to a high of 1-2 times per week (1999-2011)

Most commonly experienced stigmatizing situations include (Sarwer et al., 2008) Nasty comments from children Nasty comments from family members Inappropriate comments from

health care personnel Encountering physical barriers

Limitations

Existing stigma studies have widely employed cross-sectional and retrospective assessments spanning up to 30 years or more in lifetime Memory erosion “Repression” of traumatic or painful events Underestimation of event frequency

Limited ability to capture relationships between obesity stigma and actual health behavior (exercise/diet)

Focus on “clinical” populations

Hypotheses

H1) Rates of obesity stigma will be higher than previous retrospective reports

H2) BMI status will be positively correlated with obesity stigma

H3) Levels of obesity stigma will be inversely related to participants’ average amount of exercise (in minutes)

H4) Levels of obesity stigma will be inversely correlated with participants’ perceptions of the “healthfulness” of their daily diet

Daily Diary Assessment of Stigma Seacat & Dougal (2011; In Prep) sought to test

hypotheses and address limitations with a daily diary assessment study of obesity stigmatization

Participants 50 overweight-obese women Aged 19-61 (M = 37.90) BMI 25.00-77.90 (M = 42.56) 42% Married 90% Caucasian 60% college educated (2yr-Completion of Grad Sch.)

Daily Diary Assessment

Procedure Approved by IRB, WNE Study was advertised on weight-related

websites and blogs (e.g., Obesity Forum, Biggest Loser, My Big Fat Blog)

Participants completed a baseline demographic survey and a daily diary assessment for a period of 7 days

All participants were eligible for a raffle drawing for one of five $50 Visa check cards

Daily Diary Assessment

Measures Stigmatizing Situations Questionnaire (Myers and

Rosen, 1999) (modified) 50 items/11 sub-scales Comments from children Comments from family Isolation, feeling ignored Barriers in environment

Daily exercise/dietary habits Daily activities/places visited Daily interpersonal interactions Daily media consumption habits

Preliminary Findings

Hypothesis 1: Previous accounts using SSQ: 1x month to 2 x week Current participants reported a range of 2.74-5.24

stigmatizing events per day We also added open-ended stigma questions for

participants to respond to. Many novel events emerged, that were not captured by the SSQ “I walked outdoors today and felt embarrassed to walk

for a short time on the highway, where people who knew me might see me. I thought they would assume my car broke down, and not that I was exercising.”

Preliminary Findings- Open Ended “[ I was ] with friends at a baby shower

today so I went to McDonalds first so people wouldn't look at me eating more than I should”

“The dentist was worried I might break his chair”

“An old friend saw me and yelled "I didn't know you were pregnant”

“While outside, some of the people that drove by seemed to do the "heavy-person double take look" as they passed by”

Preliminary Findings-Open Ended “I was told that I was a bad mother

because I can't set limits as to what my son or his friends eat during sleepovers, because I can't even control myself”

“My ex-boss looked at me several times in a restaurant but acted like he didn't know me. I worked for him for 5 years but he always hated fat people”

Preliminary Findings

Hypothesis 2: Consistent with existing research and

our current hypothesis, there was a significant and positive correlation between BMI and levels of reported obesity stigma (r = .58; p < .001)

Preliminary Findings

Hypothesis 3: Supporting our hypothesis, levels of obesity

stigma were inversely correlated with participants’ average duration of daily exercise (in minutes) ( r = -.323; p =.008)

Hypothesis 4: Contrary to our predictions, levels of

obesity stigma were not significantly correlated with participants’ perceptions of daily dietary habits ( r = -.03; p = .84)

Limitations

Participant attrition Reliance upon self-report data Daily assessment may have “sensitized”

participants to perceive events they typically would not have

Lack of additional assessment methods to corroborate exercise/dietary data Pedometers Diet log

Discussion

Obesity stigma likely occurring at significantly higher rates than previously demonstrated

Stigma increases in frequency as obesity status increases

Stigma is significantly and negatively correlated with duration of physical activity in daily life

Stigma was not significantly correlated with perceptions of diet

Additional Work

Dataset also contains detailed accounts of participants’ daily interpersonal interactions, activities, places visited and media consumption habits Next steps will be to analyze these data in

conjunction with 11 subscales of SSQ to determine whether significant relationships exist

Develop briefer version of SSQ for repeated use on the basis of current participant response patterns

Future Directions

Inclusion of direct measures of physiological reactivity and exercise/diet into daily diary assessment Reactivity-

Ambulatory BP monitors Momentary data capture devices

Exercise- Exercise/diet log Pedometer

Laboratory Assessment of Obesity Stigmatization

Researchers are now beginning to focus more intently on direct, physiological assessment of responses to obesity stigmatization R. Puhl et al. Yale University B. Major et al. UC Santa Barbara J. Seacat et al. Western New England Univ.

Hypothesized that encounters with stigma should produce detectable CNS and cardiovascular reactivity

Laboratory Assessment of Stigma Though proposed, empirical relationship

between obesity stigma and reactivity is yet to be established

Majority of obesity stigma is subtle thus reactivity is likely variable and may be limited May produce frequent, low level activation

of CNS and cardiovascular system Over time, repeated arousal may contribute

to cumulative stress effects

Micro-Stressor Effects

Short-term effects- unknown Cumulative effects- theoretical

Cardiovascular reactivity Exacerbated cardiac response Increased recovery time from stressors

Potential CNS Effects- Excess cortisol production Adiposity

Current Work

Pilot testing a time series trial to assess cardiovascular and HPA activation to subtle stigma-based stressors

40 minute protocol Sex-based academic stigma in Math (St

Threat Paradigm) 2x2x2 experimental design

Prime-Negative-Male/Female Prime-Boost-Male/Female Neutral-Male/Female

Current Work

Intra-individual assessment BP, heart rate recorded at baseline and every four

minutes Salivary cortisol recorded at baseline and in 8 minute

increments thereafter Self-report at conclusion of assessment

Restrictions: No caffeine, no nicotine, no exercise w/in 24hrs No food/tooth brushing within 6 hours

Control for: Time of day, Med use (BP elevating, saliva diminishing, cortisol modulating)

Conclusion

Obesity and obesity stigmatization are increasingly prevalent in society

Obesity stigma may contribute to perpetuation of obesity epidemic and to morbidity with other health conditions

Assessment of experiences with and consequences of obesity stigmatization is in very early stages

Methods to triangulate data are most widely accepted (and funded)

Acknowledgements

Western New England University, Faculty Development Grants 2010, 2011

Dr. Sheri Tershner, Director, Neuroscience Program

Dr. Judy Cezeaux, Chair, Biomedical Engineering

WNE Students: Sarah Dougal, Cory Saucier, Aaron Krause, Christina Barbarisi and others…