Dynamic assessment of obesity stigmatization

1. Dynamic assessment of obesity stigmatization Jason D. Seacat, Ph.D. Department of Psychology, Western New England University

2. 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

3. 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

4. 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)

5. U.S. Trends and Projections National Health and Nutrition Survey

6. 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

7. 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)

8. 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

9. 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

10. 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

11. 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**

12. 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

13. 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

14. 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

15. 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.)

16. 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

17. 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

18. 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.”

19. 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”

20. 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”

21. 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)

22. 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)

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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)

32. 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)

33. 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…