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Pearl 2017
Pearl 2017
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 lipopro-
tein cholesterol were measured at baseline in 178 adults with obesity enrolled in a weight-loss trial. Medica-
tion 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 5 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 5 1.46, 95% CI 5 1.002.13, P 5 0.052). Higher WBI predicted greater odds of having high
triglycerides (OR 5 1.88, 95% CI 5 1.143.09, P 5 0.043). Analyzed categorically, high (vs. low) WBI pre-
dicted 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.
Obesity (2017) 25, 317-322. doi:10.1002/oby.21716
1
Department of Psychiatry, Center for Weight and Eating Disorders, Perelman School of Medicine at the University of Pennsylvania, Philadelphia,
Pennsylvania, USA. Correspondence: Rebecca L. Pearl (rpearl@mail.med.upenn.edu) 2 Department of Psychology, Duke University, Durham, North
Carolina, USA 3 Department of Biobehavioral Health Sciences, School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
4
Department of Medicine Gastrointestinal Unit, MGH Weight Center, Massachusetts General Hospital, Boston, Massachusetts, USA 5 Department of
Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA 6 Department of Psychiatry and Behavioral
Sciences, Childrens Hospital of Philadelphia, Philadelphia, Pennsylvania, USA 7 Department of Medicine, Institute for Diabetes, Obesity, and Metabolism,
Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
experiences of weight stigma (5,6), although experiencing and inter- studies have reported associations between internalized racism and
nalizing stigma are considered related yet independent constructs greater risk of abdominal obesity, insulin resistance, and other indices
(6,7). Consistent with research that cognitive appraisal of a stressful of obesity-related health (30). However, no study to date has investi-
life event is more predictive of negative psychological outcomes gated the relationship between WBI and cardiometabolic risk factors
than the event itself (8), recent findings suggest that WBI (a cogni- commonly associated with obesity. Metabolic syndrome, which refers
tive process) may be a more robust predictor of psychological dis- to a cluster of risk factors for cardiovascular disease and type 2 diabetes
tress than the experience of weight stigma alone (9). (31), is particularly relevant to investigate. Approximately 35% to 40%
of adults in the U.S. have metabolic syndrome, and 60% of adults with
Additional research has begun to establish that experiencing (or per- obesity meet criteria for this diagnosis (32). Individuals with metabolic
ceiving) weight stigma, principally weight discrimination, is associ- syndrome have a twofold increased risk for cardiovascular disease and a
ated with physical health consequences. In a study of two large, repre- fivefold risk for type 2 diabetes (31,33).
sentative samples that followed participants in the U.S. longitudinally
for 4 to 10 years, Sutin et al. (10) reported that perceiving weight dis- This study examined the relationship between WBI and metabolic
crimination increased risk of mortality by 57% over and above the syndrome. We hypothesized that in persons with obesity, higher lev-
effects of mental and physical health risk factors. Other studies have els of WBI would be associated with increased odds of having meta-
also demonstrated that perceived weight discrimination is associated bolic syndrome. We also explored the relationships between WBI
with increases in weight, waist circumference, and, for those in the and the individual cardiometabolic risk factors that constitute meta-
overweight range, the development of obesity over time (11,12). bolic syndrome, in order to determine which risk factors may be
Among individuals with and without type 2 diabetes, weight-based more strongly linked to WBI.
discrimination is also associated with poorer glycemic control, even
when controlling for body mass index (BMI), depressive symptoms,
and other relevant health variables (13,14).
Methods
A combination of biological and behavioral pathways may explain the Participants
associations between weight stigma and poor physical health (15). Participants were 178 adults with obesity recruited from the commu-
Stigma broadly is considered a chronic stressor (16), which can elicit nity to participate in a weight-loss trial. The primary purpose of the
a biochemical stress response marked by changes in autonomic study was to test the effects of a 1-year weight-loss maintenance pro-
response, hypothalamic-pituitary-adrenocoritcal axis activation, oxi- gram, to which participants were randomly assigned if they lost 5%
dative stress, and inflammation (15). For example, experimental stud- of initial weight during a 14-week diet run-in period. Eligible partici-
ies that exposed participants (predominantly white women) to weight pants had a BMI 33 kg/m2 (or 30 kg/m2 with comorbidities) and
stigma have demonstrated heightened blood pressure and increased 55 kg/m2 and were: age 21 to 65 years; weight stable with no history
cortisol reactivity (17,18). Increased appetite and/or physiological of bariatric surgery; not on medications that would affect weight or on
arousal resulting from these biochemical changes, combined with medications contraindicated with the weight-loss medication used in
emotional responses, may contribute to observed increases in calorie the 1-year maintenance study; and under the care of a primary care
consumption and binge eating in individuals who have been directly physician. They also were free of: current, severe depressive episodes;
exposed to or experienced weight stigma (19,20). Individuals who suicidal ideation; type 1 or type 2 diabetes; uncontrolled hypertension;
report weight-stigmatizing experiences also tend to avoid physical cardiovascular, valvular heart, hepatic, renal, or uncontrolled thyroid
activity (21). In addition, individuals who perceive or experience disease; or other medical conditions that could compromise the partic-
weight stigma in health care settings are more likely to avoid or delay ipants ability to complete the weight-loss program. Only baseline
preventive care, thus increasing risk for disease progression (22). data were analyzed in the current study. The study was approved by
the University of Pennsylvania Institutional Review Board.
These studies examining the relationship between weight stigma and
physical health have not included assessments of WBI, and gener-
ally less is known about the relationship between WBI and cardio- Procedures
metabolic markers of health. In several studies, correlations have Participants were recruited from the community through print, radio,
been found between WBI and poorer self-reported health, increased and Web advertisements and screened over the phone for eligibility.
binge eating, and reduced physical activity (6,20,23-27), suggesting Following the initial phone screen, interested participants were eval-
that similar pathways to poor health may exist for WBI as with uated in person by trained clinicians for eligibility and appropriate-
weight stigma perpetrated by others. Several studies have demon- ness. All participants underwent a medical exam with a physician or
strated that WBI is a partial mediator between experiences of weight nurse practitioner before enrollment, which included assessment of
stigma and poor health behaviors (such as uncontrolled eating and current medications. At this initial screening visit, blood pressure
reduced exercise) (5,6). Additionally, one study found that BMI was and waist circumference were measured, and blood draws completed
only associated with poor health-related quality of life among indi- to obtain measures of fasting blood glucose, triglycerides, and high-
viduals with high versus low WBI (28). Thus, it is possible that acti- density lipoprotein (HDL) cholesterol. Height and weight also were
vation of internalized, negative beliefs following or independent of measured at this screening visit, and weight was measured again
stigmatizing experiences may lead to heightened stress and subse- during the first week of the study (prior to any weight-loss interven-
quent maladaptive coping behaviors (e.g., binge eating). tion). Questionnaires were administered online (via REDcap) or in
hard copy form via mail up to 2 weeks prior to the start of the pro-
Although limited research has investigated cardiometabolic risk associ- gram. Data for the present study are based on these screening meas-
ated with other forms of internalized stigma (e.g., racism) (29), some ures, obtained before the 14-week run-in diet.
race (P < 0.001). Post hoc paired t-tests revealed that black partici-
TABLE 2 Odds ratios (95% confidence intervals) for weight
pants scored significantly lower on the WBIS than white partici-
bias internalization as a continuous measure pants: mean (6SD) scores for black participants 5 3.36 6 1.08, and
Metabolic High triglycerides for white participants 5 4.22 6 1.15 (P < 0.001). WBIS scores corre-
lated significantly with depressive symptoms (r 5 0.38, P < 0.001).
syndrome and/or medication
Age, sex, and BMI were not significantly associated with WBIS
Block 1 1.41 (1.011.97)* 1.79 (1.212.64)** scores.
Block 2 1.46 (1.002.13)1 1.88 (1.143.09)*
Primary analysis: Metabolic syndrome
Block 1: Weight bias internalization, body mass index, and depressive symptoms.
Block 2: Block 1 plus demographics (age, sex, race/ethnicity). Table 2 presents the results from the logistic regression analysis that
Due to missing waist circumference data, N 5 151 for metabolic syndrome. examined the association between WBI and metabolic syndrome,
N 5 159 for triglycerides/medication. controlling for demographics, BMI, and depressive symptoms. When
1
P 5 0.052; *P < 0.05; **P < 0.01.
controlling for BMI and depressive symptoms, participants with
higher WBIS scores had greater odds of meeting criteria for meta-
calculated partial correlations (controlling for demographics, BMI, bolic syndrome (OR 5 1.41, P 5 0.042). However, when demo-
and PHQ-9 scores) between WBIS scores and continuous variables graphics were included in the model, this relationship was no longer
of each cardiometabolic risk factor. Additionally, we included sup- statistically significant (OR 5 1.46, P 5 0.052). Participant age was
plementary analyses in which we constructed the same six logistic the only covariate associated with metabolic syndrome in the model
regression models, but with WBI defined categorically as high (OR 5 1.05, P 5 0.004).
versus low based on tertiles. This dichotomization of WBI is con-
sistent with prior research (28,30).
Secondary analyses: Cardiometabolic risk factors
To explore the factors responsible for heightened odds of meta-
Missing data. At baseline, eight participants were missing waist bolic syndrome, we examined the associations between WBI and
circumference measurements. These participants were excluded from each component of the condition via five separate logistic regres-
analyses that included waist circumference or metabolic syndrome sion models (all controlling for demographics, BMI, and PHQ-9
diagnosis as outcome variables. scores) and partial correlations (controlling also for respective
medication use). Of the logistic regression models, only the model
that tested the relationship between WBI and high triglycerides
was significant (see Table 2). Participants with higher WBIS
Results scores had greater odds of having high triglycerides and/or taking
Participant characteristics medication for dyslipidemia, even when controlling for all covari-
Completed study questionnaires were obtained from 159 partici- ates (OR 5 1.88, P 5 0.013). Only one participant did not meet the
pants, whose characteristics are summarized in Table 1. The major- waist circumference criterion, and no associations between this
ity of participants were women and black. Table 1 also presents a risk factor and WBIS scores emerged. Associations were not sig-
summary of the number of participants meeting criteria for meta- nificant between WBIS scores and blood pressure or glucose.
bolic syndrome, as well as participants mean weight, height, BMI, Only eight participants met the glucose/medication criterion (due
and scores on the WBIS and PHQ-9. to the participant exclusion criterion of type 2 diabetes). WBIS
scores correlated positively with triglycerides (P 5 0.021) and neg-
Race/ethnicity was coded into three categories of non-Hispanic atively with HDL cholesterol (P 5 0.009). However, these correla-
white, non-Hispanic black, and all other racial/ethnic groups. Analy- tions were not statistically significant when controlling for all
sis of variance revealed significant differences in WBIS scores by covariates (see Table 3).
TABLE 3 Correlations (and partial correlations) between weight bias internalization and cardiometabolic risk factors
HDL Waist
Variable cholesterola FBG circumference Triglycerides DPB SBP
Weight bias internalization 20.21** (20.13) 0.04 (0.02) 0.10 (0.02) 0.18* (0.13) 0.08 (0.07) 0.06 (0.09)
Systolic blood pressure (SBP) 0.08 (0.06) 0.18* (0.11) 0.12 (0.06) 0.07 (0.04) 0.58*** (0.59***)
Diastolic blood pressure (DPB) 20.03 (20.02) 0.10 (0.06) 0.10 (0.05) 0.09 (0.06)
Triglyceridesa 20.41*** (20.40***) 0.15 (0.08) 20.03 (20.01)
Waist circumferencea,b 20.07 (0.06) 0.14 (0.05)
Fasting blood glucose (FBG) 20.13 (20.13)
Partial correlations control for age, sex, race/ethnicity, body mass index, depression, and respective medication use (for blood pressure, triglycerides, and glucose).
a
Variable was transformed using the natural logarithm.
b
N 5 151 for waist circumference due to missing data.
*P < 0.05; **P < 0.01; ***P < 0.001.
(6,23), and thus are more likely to avoid physical activity (21). Fur-
TABLE 4 Odds ratios (95% confidence intervals) for high ther research is needed to determine the specific biological and/or
versus low weight bias internalization behavioral pathways that could account for unfavorable lipid levels.
For example, advanced lipoprotein testing could help to determine
Metabolic High triglycerides
whether the observed effects are diet-induced versus metabolically
syndrome and/or medication
endogenous. In-depth dietary analysis could also examine whether
Block 1 2.68 (1.056.88)* 5.64 (1.7218.54)** individuals with high WBI consume more high-fat foods, which
Block 2 3.19 (1.069.56)* 6.13 (1.3727.46)* could potentially account for the elevated triglyceride levels
observed in this study. The correlation between WBI and triglycer-
ides was not significant when controlling for covariates, and waist
Block 1: Weight bias internalization, body mass index, and depressive symptoms.
Block 2: Block 1 plus demographics (age, sex, race/ethnicity). Categorization of circumference and blood glucose control were largely homogeneous
high versus low weight bias internalization was based on tertiles: high 4.18, low in this sample. Thus, replication is required, and further research
3.09.
Due to missing waist circumference data, N 5 103 for metabolic syndrome.
with a more heterogeneous representation of these risk factors (e.g.,
N 5 109 for triglycerides/medication. including individuals with type 2 diabetes) is needed.
*P < 0.05 **P < 0.01.
This study was cross-sectional in design, precluding conclusions
about causality. Thus, a converse relationship could be present, in
Supplementary analyses which poorer physical health (e.g., metabolic syndrome) may lead
Consistent with prior research in which internalized stigma was individuals with obesity to be more prone to internalizing weight
dichotomized to determine effects of high versus low values bias. Individuals with obesity frequently experience weight stigma
(28,30), we examined the relationship between WBI, metabolic syn- in health care settings (22); increased need for health care services
drome, and the individual risk factors in six additional logistic due to poor health may consequently increase exposure to stigma
regression models (controlling for all aforementioned covariates), in and heighten vulnerability to internalizing it. Heightened disease
which WBI was categorized as high versus low based on tertiles. burden may also increase susceptibility to self-blame due to the per-
Cutoff scores of 4.18 (n 5 57) and 3.09 (n 5 52) were used to define ceived controllability of weight (2). A longitudinal study of individ-
high and low scores, respectively. Logistic regression analyses con- uals with varying levels of WBI at baseline, but without obesity-
trolling for all covariates demonstrated that participants high in WBI related comorbidities, could help to clarify the temporal relationship
had three times greater odds of meeting criteria for metabolic syn- between WBI and risk of metabolic syndrome.
drome (OR 5 3.19, P 5 0.039), and six times greater odds of having
high triglycerides and/or taking medication (OR 5 6.13, P 5 0.018) This sample was unique in its predominant composition of black
than participants low in WBI (see Table 4). women, which allowed us to examine WBI among a group of indi-
viduals with obesity that is often not well represented in research
addressing this topic. Black participants had lower levels of WBI on
average, which may reflect reduced vulnerability to body dissatisfac-
Discussion tion among black women (39). Black children and adults also gener-
This study of treatment-seeking individuals with obesity found ally have lower triglyceride levels and are thus less likely to be
diagnosed with metabolic syndrome (40). Given these racial differ-
mixed results concerning the relationship between metabolic syn-
ences, it is possible that the relationship between WBI, triglycerides,
drome and WBI. This relationship was not significant when all
and metabolic syndrome may differ by race as well. We may have
covariates were included in a regression model in which WBI was
been underpowered in our analyses to detect significant racial differ-
represented continuously. However, the odds of having metabolic
ences in the regression models, as well as sex differences due to the
syndrome were significantly heightened among participants catego-
relatively small number of men in the present sample. Prior studies
rized as having high (versus low) levels of WBI. WBI has been
examining the relationship between weight discrimination and physi-
shown previously to be associated with binge eating (20), reduced cal health outcomes have used large, nationally representative data-
physical activity motivation and engagement (6,23), and poorer self- sets (10-12), in which small effects may be better detected. We rec-
reported physical health (24,25). However, this is the first report of ommend that future large-scale investigations of obesity and
which we are aware to demonstrate a possible association between healthparticularly cardiovascular disease riskincorporate the
WBI and metabolic syndrome. WBIS into assessment batteries in order to accumulate more data
and test for potential moderators such as sex and race.
The only individual component of metabolic syndrome that was sig-
nificantly associated with WBI was high triglycerides/use of medica- Our findings pertain only to individuals with obesity seeking treat-
tion for dyslipidemia. Internalized weight bias could elicit a chronic ment for weight loss and may not generalize to the broader popula-
stress response similar to that observed in reaction to experiences of tion of individuals with obesity. Prior evidence suggests that
weight stigma, such as heightened levels of oxidative stress and cor- treatment-seeking individuals with obesity exhibit heightened rates
tisol secretion (15). The act of self-stigmatizing may lead to a state of psychopathology (including depression) in comparison with non-
of physiological arousal that itself increases risk for metabolic treatment seeking individuals (41). However, given this studys
abnormalities through biological pathways (e.g., cortisol secretion). exclusion criteria of severe depression or use of antidepressant medi-
This state of physiological and affective stress may also lead indi- cation, our clinical sample had relatively low levels of depressive
viduals to cope by eating unhealthy food or binge eating (38). Addi- symptoms. The mean WBIS score in this sample was lower than in
tionally, individuals with high WBI exhibit diminished self-efficacy other recent studies of treatment-seeking samples (42), which may
to exercise due to endorsing negative stereotypes, such as laziness reflect the relatively good mental and physical health of this sample.
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