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Weight‐based teasing is associated with gain in BMI and fat mass among children and adolescents at‐risk for obesity: A longitudinal study

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Background Youths with overweight and obesity report frequent instances of weight‐based teasing. However, little is known about the prospective associations between weight‐based teasing and changes in body composition among youth. Objective To assess associations between weight‐based teasing and changes in body mass index (BMI) and fat mass in a longitudinal study of youths with, or at‐risk for, overweight and obesity. Methods One hundred ten youths with, or at‐risk for, overweight participated in a longitudinal observational study. The Perception of Teasing Scale was administered at baseline. Height, weight, and body composition were obtained at baseline and at follow‐ups (range: 1‐15 years). Results Mean age at baseline was 11.8 years; 53% had overweight/obesity; 36% were non‐Hispanic Black; 55% were female; mean follow‐up from baseline: 8.5 years. Adjusting for covariates and repeated measures of BMI or fat mass, linear mixed models revealed that weight‐based teasing was associated with greater gain of BMI and fat mass across the follow‐up period (ps ≤ .007). Adjusting for covariates, youths reporting high weight‐based teasing (two standard deviations above the mean) experienced a 33% greater gain in BMI (an additional 0.20 kg/m²) and a 91% greater gain in fat mass (an additional 0.65 kg) per year compared with peers who reported no weight‐based teasing. Conclusions Among youths with, and at‐risk for, overweight and obesity, weight‐based teasing was associated with greater weight and fat gain.
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Weight-Based Teasing is Associated with Gain in BMI and Fat Mass Among Children and
Adolescents At-Risk for Obesity: A Longitudinal Study
Published in: Pediatr Obes 2019:e12538 PMID 31144471
Natasha A. Schvey, PhD,a,b Shannon E. Marwitz, BS,b Sarah J. Mi, BS,b
Ovidiu A. Galescu, MD,b Miranda M. Broadney, MD, MPH,b Deborah Young-Hyman, PhD,b
Sheila M. Brady, MSN, CRNP,b James C. Reynolds, MDb, Marian Tanofsky-Kraff, PhD,a,b
Susan Z. Yanovski, MD,b and Jack A. Yanovski, MDb
aUniformed Services University of the Health Sciences (USUHS)
4301 Jones Bridge Road Bethesda, MD 20814, USA
bSection on Growth and Obesity, Program in Developmental Endocrinology and Genetics,
Eunice Kennedy Shriver National Institute of Child Health and Human Development,
National Institutes of Health, DHHS
10 Center Drive, Building 10, Room 1-3330, MSC 1103
Bethesda, MD 20892-1103, USA
Correspondence to:
Natasha A. Schvey, PhD
Assistant Professor
Department of Medical & Clinical Psychology
Uniformed Services University of the Health Sciences (USUHS)
Office: B3039A
TEL: 301-295-9880
Email: natasha.schvey@usuhs.edu
Clinical Trials Registry Site: Clinicaltrials.gov. ID # NCT00001522
Key Words: Adolescents, weight-based teasing, BMI, adiposity
Running Title: Weight-Based Teasing
1
Weight-Based Teasing is Associated with Gain in BMI and Fat Mass Among Children and
Adolescents At-Risk for Obesity: A Longitudinal Study
Abstract
Background: Youths with overweight and obesity report frequent instances of weight-based
teasing. However, little is known about the prospective associations between weight-based
teasing and changes in body composition among youth.
Objectives: To assess associations between weight-based teasing and changes in BMI and fat
mass in a longitudinal study of youths with, or at-risk for, overweight and obesity.
Methods: One hundred ten youths with, or at-risk for, overweight participated in a longitudinal
observational study. The Perception of Teasing Scale was administered at baseline. Height,
weight, and body composition were obtained at baseline and at follow-ups (range: 1-15 years).
Results: Mean age at baseline was 11.8y; 53% had overweight/obesity; 36% were Non-Hispanic
Black; 55% were female; mean follow-up from baseline: 8.5y. Adjusting for covariates and
repeated measures of BMI or fat mass, linear mixed models revealed that weight-based teasing
was associated with greater gain of BMI and fat mass across the follow-up period (ps ≤ .007).
Adjusting for covariates, youths reporting high weight-based teasing (two standard deviations
above the mean) are predicted to gain an additional .20 kg/m2 in BMI and .65 kg of fat mass per
year compared to peers who report no weight-based teasing.
Conclusions: Among youths with, and at-risk for, overweight and obesity, weight-based teasing
was associated with greater weight and fat gain.
2
Implications and Contribution
Among youths with or at-risk for obesity, weight-based teasing was associated with a
greater rate of BMI and fat mass gain over time, after adjusting for relevant variables, including
baseline measures of these two variables. Weight-based teasing may exacerbate risk for excess
weight and fat gain throughout development.
3
Weight-Based Teasing is Associated with Gain in BMI and Fat Mass Among Children and
Adolescents At-Risk for Obesity: A Longitudinal Study
Overweight and obesity in youth are associated with a host of negative outcomes,
including type 2 diabetes, hypertension, dyslipidemia, sleep apnea, and orthopedic complications
(1,2). In addition to the medical sequelae of obesity, youths with excess weight also report
frequent instances of weight-related victimization and stigmatizing experiences across multiple
domains. In fact, weight-based teasing (WBT) is consistently one of the most common reasons
cited for bullying among youth; over 90% of high school students have witnessed peers with
overweight/obesity being teased due to their weight (3). Among youths with overweight/obesity,
up to 60% report WBT by peers and family members (4,5). Others who engage in WBT include
teachers, coaches, and healthcare providers (6). Although some propose that weight stigma might
be beneficial in that it ostensibly could motivate healthy behavioral changes (7), an extensive
body of research indicates that the experience of weight stigma is associated with adverse
psychological consequences among both children and adults, including low self-esteem, social
isolation, truancy, and suicidal thoughts and behaviors (8-11). Importantly, WBT is also
associated with a host of behaviors and psychological constructs that may contribute to and
exacerbate excess weight, including body dissatisfaction, compensatory behaviors, avoidance of
physical activity and exercise, eating in secret, and binge eating (9,11-13).
To date, few longitudinal studies have assessed the effects of weight stigma on weight
and body composition and these have primarily focused on adult samples (14,15). However,
childhood marks a critical time for the study of weight and fat gain trajectory given that weight
tends to track into adulthood, such that youths with overweight and obesity are much more likely
4
to become adults with overweight and obesity (16). Only a small number of studies have
assessed the longitudinal associations between WBT and weight-related pressures on weight and
health indices among youth. One such study (17) assessed WBT and BMI among adolescents in
1999 and again in 2015. Findings indicated that WBT (assessed by a single item measure) in
adolescence predicted higher self-reported BMI 15 years later. Another study followed a sample
of girls from the age of 10 until 19 and found that being labelled “too fat” at baseline predicted
obesity nine years later, after controlling for baseline BMI. In a third study, authors found that
perceived pressure to be thin from parents and peers was associated with greater gains in BMI
and body fat mass at 1-year follow-up (18). The relatively scant literature on the longitudinal
effects of WBT among youth indicate that WBT and weight-related pressures may increase risk
for excess weight and fat gain over the course of development and may increase the likelihood of
a child developing obesity in young adulthood (17-19). Therefore, WBT may play a role in the
maintenance and exacerbation of overweight/obesity during youth.
Given the preliminary data on weight-related stigma and weight gain, additional
longitudinal research is needed to elucidate the relationship between WBT and body
composition. We therefore investigated whether WBT reported at baseline was associated with
change in measured BMI and fat mass among youths over an extensive (up to 15 years) follow-
up period. Based upon the existing data demonstrating that weight stigma and weight-related
pressures may predict weight gain among both adults and youths (14,15,17-19), we hypothesized
that greater WBT reported at baseline would be associated with a steeper gain in BMI and fat
mass over adolescence and early adulthood.
5
Materials and Methods
Participants and procedures
Participants were recruited through mailings to local family physicians, pediatricians, and
school districts for a longitudinal, observational study (Clinicaltrials.gov. ID # NCT00001522)
aimed at identifying biological and behavioral factors predictive of excessive weight gain and
obesity development in U.S. non-Hispanic Black and White Children, as previously described
(20). Participants were enrolled in the study between July 12, 1996 and July 6, 2009, and invited
for annual follow-up visits for up to 15 years. Participants who did not attend a visit were still
invited to return each subsequent year. Only children with at least one follow-up visit were
included in the present study. Children were eligible for the study if they had either a BMI
percentile 85th or two parents with overweight /obesity (BMI 25 kg/m2) but were otherwise
in good general health. In addition, the self-reported race of the participant’s four grandparents
must have been identified either as all non-Hispanic White or all non-Hispanic Black. Prior to
assessments, parents provided informed consent and children provided written assent. The study
was approved by the National Institute of Child Health and Human Development Institutional
Review Board. The impact of teasing was not one of the primary study endpoints thus the current
study should be considered an exploratory analysis.
Anthropometrics
Participants presented to an 8:00am appointment following a fast initiated at 10:00pm the
night prior. Height and weight were obtained with participants clothed, but not wearing shoes.
Height was measured in triplicate to the nearest millimeter by a stadiometer (Holtain,
Crymmych, Wales) calibrated before each measurement and weight was measured to the nearest
0.1 kg with a calibrated digital scale (Scale-Tronix, Wheaton, IL) from which body mass index
6
(BMI; kg/m2) was calculated. Body composition was measured using Dual Energy X-Ray
Absorptiometry (DXA) to determine lean and fat mass. Given the extensive follow-up period,
several different DXA machines were used over the course of the study duration. All participants
underwent a medical history and a physical examination performed by an endocrinologist or a
nurse practitioner.
Questionnaires
The Perception of Teasing Scale (POTS) (21) is a self-report questionnaire that assesses
the frequency of teasing related to both competence and high weight status, as well as the effect
on the targeted individual. For the purposes of the present study, the weight-based teasing
frequency subscale (e.g., People made fun of you because you were heavy; People called you
names like "fatso.") was assessed (6 items; Cronbach’s α = .81). Participants were asked to
indicate how often each experience had occurred (ranging from 1= never to 5= very often). Total
scores range from 6 to 30, with higher scores indicating greater frequency of WBT. The POTS
has demonstrated stable factor structure, acceptable internal consistency, and convergent validity
with related constructs (20-22). A pencil and paper version of the POTS was administered during
the in-person baseline clinic visit. All participants completed the POTS in its entirety.
The Hollingshead scale (23) was used to assess socioeconomic status (SES) based on
parental occupation and education. Total scores range from 1 to 5, wherein lower scores indicate
higher SES. The Hollingshead is a widely used measure of SES and has shown reliability across
diverse samples and high correlation with other measures of SES (24).
Data Analytic Plan
All analyses were conducted using SPSS for Windows version 24 (SPSS, Inc., Chicago,
IL). Data were examined for outliers, skewness, and kurtosis. Outliers (<1% of all data points)
7
were adjusted to fall 1.5 times the interquartile range below the 25th percentile or above the 75th
percentile. In accordance with recommended practices (25,26), WBT and BMI were examined in
all models as continuous variables (except to determine the frequency of WBT reported). A
series of linear mixed models using repeated measures for BMI/fat mass (kg) were conducted, all
controlling for sex, race, SES (27-29), age at baseline, total amount of time in the study (years),
and baseline levels of BMI/fat mass. Repeated measures of height (cm) were also included in the
model of fat mass. For each model, both the main effect of WBT and the interaction of WBT by
time in study were assessed. Whereas BMI z-score and/or BMI percentile are considered optimal
indices of adiposity among youths for a single (cross-sectional) measurement, data indicate that
BMI is, in fact, preferable for the assessment of change in adiposity over time among youths
(30,31); therefore, the current analyses utilize BMI. For ease of interpretation, Figure 1 depicts
predicted values for no WBT (POTS score = 6), the midpoint of WBT (POTS score = 18), and
the maximum possible WBT (POTS score = 30), controlling for covariates as specified in the
Methods. Differences were considered significant when p values were 0.05. All tests were two-
tailed. As the current study was a tertiary investigation, there was no a priori power calculation.
Results
Participant characteristics
One hundred ten youths (55% female) with overweight/obesity (BMI ≥ 85th percentile;
53%) or who did not have overweight (BMI < 85th percentile; 47%) but who were considered at-
risk for adult obesity because they had two parents with overweight or obesity participated. The
racial distribution of the sample was 65% non-Hispanic White and 35% non-Hispanic Black.
Average age at baseline was 11.8 ± 2.4y. Twenty percent of youth participated between 1 and 5
8
years, 37% participated between 5 and 10 years, and 42% participated between 10-15 years. The
mean time to the last follow-up was 8.5 ± 3.7y. The mean number of study visits was 9.3 ± 4.9y,
such that the mean age at the last follow-up visit was 20.3 ± 4.1y. Age and BMI were associated
with number of follow-up visits, such that participants who were younger and had a lower BMI
at baseline came in for more visits (p ≤ .005). Race and sex were unrelated to number of visits.
Mean SES for the sample was 2.92 ± 1.13. See Table 1 for demographic information.
Weight Based Teasing
Responses on the POTS were dichotomized to ascertain the proportion of youths who
reported WBT. Responses of “occasionally”, “sometimes”, “often”, and “frequently” were coded
as yes while a response of “never” was coded as no. Results indicated that 43% of all
respondents (21% of those who did not have overweight and 62% of those with overweight, χ2 =
18.8, p < .001) reported at least one instance of WBT.
Weight Based Teasing and BMI
Adjusting for relevant variables, WBT at baseline was significantly associated with BMI
throughout the follow-up period (main effect of weight-based teasing: F = 29.48, p < .001). In
addition, the interaction of WBT by time in study was significant such that youths reporting
greater WBT also evidenced a steeper gain in BMI across the follow-up period (F = 7.33, p =
.007) (See Table 2 and Figure 1A). More specifically, those with no reported WBT (POTS score
= 6) were estimated to gain .57 BMI units per year while those who scored two standard
deviations above the mean (POTS score = 15.07) were estimated to gain .76 BMI units per year
(an additional .20 units of BMI), adjusting for relevant covariates. Thus, youth who reported high
levels of WBT experienced a 33% greater gain in BMI per year compared to youth with no
WBT.
9
Weight Based Teasing and Fat Mass
In a similar model, adjusting for relevant variables including height (cm), WBT at
baseline was significantly associated with fat mass throughout the follow-up period (main effect
of WBT: F = 22.83, p < .001) and with a steeper increase in fat mass gain over time (interaction
of WBT and time in study: F = 14.93, p < .001; See Table 2 and Figure 1B). Those with no WBT
(POTS score = 6) were estimated to gain .71 kilograms of fat mass per year whereas those who
scored two standard deviations above the mean (POTS score = 15.07) were estimated to gain
1.36 kilograms of fat per year (an additional .65 kilograms of fat) adjusting for relevant
covariates. Therefore, youth reporting high levels of WBT experienced a 91% greater gain in fat
mass per year compared to youth with no WBT.
Discussion
In this study of youths with childhood-onset overweight or obesity or who were at-risk
for adult overweight/obesity, 43% of the total sample and 62% of youths with
overweight/obesity reported the presence of at least one instance of WBT. Furthermore, WBT
was associated with BMI and fat mass throughout childhood, adolescence, and early adulthood,
such that youths who were teased more at baseline started heavier and remained heavier
throughout the follow-up period. Importantly, WBT was also associated with greater rates of
both BMI and fat mass gain over time, such that youths who reported high WBT (two standard
deviations above the mean) evidenced a 33% greater gain in BMI (.76 versus .57) and a 91%
greater gain in kilograms of fat (1.36 versus .71) per year as compared to youth who report no
WBT even after adjusting for baseline levels of these variables.
Taken together, these data suggest that WBT may promote greater gains in BMI and fat
mass among youths at-risk for adult obesity, and that the experience of WBT in youth might
10
contribute to the likelihood of developing overweight/obesity as an adult. Alternatively, children
at high risk for excessive weight gain might be more prone to report WBT or an unmeasured
factor might place children at-risk both for rapid weight gain and WBT. For instance, the
presence of disinhibited eating may be one such factor that confers vulnerability to both rapid
weight gain (32) and WBT, especially in the home and school environments where disinhibited
eating behavior might be evident. There are several possible mechanisms, both psychological
and physiological, that might account for the present findings. For instance, the associations of
weight stigma with unhealthy weight control behaviors, binge eating, body dissatisfaction, and
avoidance of physical activity are well-documented (33-36), all of which might collectively
place an individual at increased risk for excess weight and adiposity gain. Thus, a child who is
teased for his/her weight might be more likely to experience body dissatisfaction and engage in
unhealthy behaviors, such as binge eating, to cope with subsequent negative affect (37,38).
Additionally, weight stigma is a source of biochemical stress and may contribute to elevated
secretion of the glucocorticoid stress hormone, cortisol. Indeed, extant research among adults has
observed increases in oxidative stress and cortisol in response to weight stigmatizing stimuli (39-
41). Chronically elevated cortisol may, in turn, stimulate the appetite, blunt satiety cues, inhibit
self-control, and increase preference for highly palatable, energy-dense food (42-46), all of
which may increase risk for overweight and obesity. Additional longitudinal research is required
to elucidate the biobehavioral mechanisms accounting for the association between WBT and
weight and fat gain.
Our findings support previous research among youths and adults linking WBT and
weight stigma to adverse health- and weight-related outcomes over time. Given that prior studies
have detected differences in the effects of weight-related pressures, such as being labelled “too
11
fat” and pressure to be thin, depending on the nature, perpetrator, and setting (17,18), future
studies are required to ascertain if various sources (e.g., parents versus peers) and types (e.g.,
relational versus physical) of WBT have differential effects on youth. The measure of WBT in
the current study assessed fairly overt WBT, for instance, being laughed at, made fun of, and
called names, however, previous research has documented adverse effects of subtler forms of
bias, such as being labelled “too fat” and pressure to be thin (18,19,47). As weight stigma may
take many forms among youth, ranging from cyberbullying via social media to social exclusion
and rumor spreading, further research is needed to elucidate the unique effects of various facets
of stigma. In addition, given the limited sample variance in the present study (all youths were at
high-risk for adult obesity), future research should examine these associations among more
heterogeneous samples.
Findings from the present exploratory study, if replicated in future research, may indicate
a need to assess WBT among youths, and in particular, those at high-risk for adult obesity. In
addition, continued efforts should be made to educate the public about the potentially harmful
effects of WBT; this may be especially important within families and schools given that many
children with overweight report WBT from parents, siblings, and classmates (3,6,8) and social
exclusion may be common among youth with high weight (4). Because childhood and
adolescence are times of increased vulnerability to WBT, disordered eating, and the onset of
overweight/obesity (48-52), it may be beneficial to assess youth for WBT, which could identify
them as being at increased risk for weight and fat gain over time.
Study strengths include the longitudinal design and extensive follow-up period. The
present study also included the repeated measurement of height, weight, and body composition.
Limitations of the study include the limited sample variance; more specifically, all participants
12
were at high-risk for adult obesity, and only non-Hispanic White and Black youths were
included. Our measure of WBT was only administered at a single baseline visit; therefore, we
were unable to assess changes in WBT over time. In addition, this measure assesses teasing
based on high weight status, therefore, we were unable to assess teasing that may have occurred
due to low weight. Finally, because of machine obsolescence, several different DXA machines
had to be used to measure body fat mass over the many years of study follow-up. It remains
possible that the magnitude of differences in fat mass may have been affected. Since there was
no evidence that the machine used for DXA analysis varied systematically according to POTS
score, this issue appears unlikely to explain the observed associations of WBT with undue gain
of adipose tissue.
Conclusion
In conclusion, the experience of WBT may place children and adolescents at increased
risk for excess weight and fat gain throughout the developmental period. As adolescence marks a
critical period for the study of weight gain (53), it will be important to further explore the effects
of WBT and weight-related pressures on indices of weight and health throughout development
and to identify both risk and protective factors. The present findings, if replicated in other
samples, may provide a foundation upon which to initiate clinical pediatric interventions to
determine whether reducing WBT affects weight and fat gain trajectory.
13
Acknowledgments: Supported by Intramural Research Program Grant Z1A-HD-00641 from the
National Institute of Child Health and Human Development (to JAY). Funding sources had no
involvement in the study design, data collection and analysis, preparation of the manuscript, or
decision to submit the article for publication. JAY is a Commissioned Officer in the United
States Public Health Service. The corresponding author affirms that she has listed everyone who
contributed significantly to the work. JAY conceived and designed the study. All co-authors
assisted with participant visits and data collection. The first draft of the manuscript was written
by NAS; it was revised to incorporate the suggestions and edits of all co-authors. All authors had
final approval of the submitted and published versions. The authors wish to acknowledge the
support of Dr. Cara Olsen, who provided consultation on statistical analyses and interpretation.
None of the authors accepted payment for the production of the current manuscript. Portions of
this work were reported at the 2016 meeting of The Obesity Society and the 2017 meeting of the
Association for Psychological Science. Disclaimer: The opinions and assertions expressed herein
are those of the authors and are not to be construed as reflecting the views of USUHS or the U.S.
Department of Defense.
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WEIGHT-BASED TEASING 18
18
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WEIGHT-BASED TEASING 19
19
Figure Legend:
Figure 1: Association of Weight-Based Teasing (WBT) with: (A) BMI and (B) Fat Mass.
For BMI: there was a significant main effect of WBT and a significant WBT x time interaction
(A; ps < .003). For Fat Mass: there was a significant main effect of WBT and a significant WBT
x time interaction (B; ps < .008).
Predicted values are shown for no WBT (POTS score = 6), the midpoint of WBT (POTS score =
18), and the maximum possible value of WBT (POTS score = 30), adjusting for covariates as
specified in the Methods.
WEIGHT-BASED TEASING 20
20
Figure 1
Measure
With Overweight
(n = 52)
Without Overweight
(n = 58)
2
Total
Sample
(n = 110)
%
%
%
Sex
5.9*
Male
34.5
57.7
44.5
Female
65.5
42.3
54.5
Race
1.8
Black
41.1
28.8
35.2
White
58.9
71.2
64.8
Presence of Weight-Based Teasing
62.0
21.2
18.8***
42.7
M
SD
N
M
SD
N
F
M
SD
N
Age (y)
12.8
2.1
58
10.6
2.1
52
30.4***
11.8
2.4
110
Socioeconomic Status
2.98
1.21
58
2.85
1.06
52
.39
2.92
1.13
110
Time to Follow-up (y)
8.2
3.8
58
8.9
3.7
52
1.1
8.5
3.8
110
BMI (kg/m2)
32.9
5.8
58
19.5
2.9
52
221.6***
26.6
8.1
110
BMI Standard Deviation Score
2.2
.5
58
.6
.9
52
160.3***
1.5
1.1
110
Fat Mass (kg)
35.1
10.2
42
11.9
6.1
39
150.1***
23.9
14.4
81
Weight-Based Teasing Score
9.4
4.0
58
6.6
1.9
52
21.3***
8.1
3.5
110
Table 2: Linear Mixed Models
Parameter
Unstandardized
Coefficient
Standard
Error
95% CI
p
A: Model Predicting BMI (kg/m2)
Intercept
8.13
7.09
-6.22 − 22.47
.26
Sex (Reference Group: Male)
-4.94
2.40
-9.79 − -.08
.05
Race (Reference Group: White)
-.93
2.33
-5.66 − 3.80
.69
Age at baseline (y)
1.40
.51
.37 − 2.43
.01
Time in study (y)
.27
.11
.06 − .49
.01
Socioeconomic Status
-1.00
1.24
-3.51 − 1.50
.42
Weight-Based Teasing
.82
.26
.29 1.34
.003
Time in study * Weight-Based Teasing
.04
.01
.02 − .06
.000
B. Model Predicting Fat Mass (kg)
Intercept
-33.09
13.71
-60.65 − -5.52
.02
Sex (Reference Group: Male)
-16.29
4.34
-25.10 − -7.49
.001
Race (Reference Group: White)
.63
.42
-7.92 9.18
.88
Age at baseline (y)
2.24
.93
.36 − 4.14
.02
Height (cm)
.18
.04
.10 − .27
.000
Time in study (y)
-.01
.26
-.53 − .50
.97
Socioeconomic Sstatus
-1.88
2.23
-6.41 2.64
.40
Weight-Based Teasing
1.33
.48
.36 2.29
.008
Time in study * Weight-Based Teasing
.10
.02
.05 .15
.000
... 3,13 A recent meta-analysis reported similar cross-sectional correlations between weight status and weight stigma across genders. 4 With regard to prospective studies, three studies did not observe gender differences with regard to the effect of weight-related stigma on weight status 11,14 or vice versa. 15 Contrary, other studies reported that previous experience of weight stigma came along with a higher risk for obesity in girls, but not in boys, 16 and that the predictive effect of weight stigma for weight status was higher among girls compared to boys. ...
... 28 Beyond that, it should be mentioned that we did not observe gender-related differences with respect to the relationship between weight-related stigma and weight status -neither cross-sectional nor longitudinal. This is in line with previous studies that also reported no gender differences, 14,15 but runs contrary to others indicating that there might be gender differences. 16,17 A closer examination reveals that moderators might explain gender differences. ...
... Ratcliffe and Ellison [14] have addressed several variables that might enhance vulnerability to WBI. Obviously, higher weight status and experienced weight stigmatization are detrimental factors for WBI in children and adolescents [11,[15][16][17][18]. Beyond that, the authors [14] postulate that body dissatisfaction, self-esteem and emotional problems are not only consequences of, but also predisposing factors for WBI. However, prospective studies for children and adolescents are lacking. ...
Thesis
Full-text available
Das Gewichtsstigma und insbesondere das internalisierte Gewichtsstigma sind bei Kindern und Jugendlichen mit negativen Folgen für die physische und psychische Gesundheit assoziiert. Da die Befundlage in diesem Altersbereich jedoch noch unzureichend ist, war es das Ziel der Dissertation, begünstigende Faktoren und Folgen von gewichtsbezogener Stigmatisierung und internalisiertem Gewichtsstigma bei Kindern und Jugendlichen zu untersuchen. Die Analysen basierten auf zwei großen Stichproben, die im Rahmen der prospektiven PIER-Studie an Schulen rekrutiert wurden. Die erste Publikation bezieht sich auf eine Stichprobe mit Kindern und Jugendlichen im Alter zwischen 9 und 19 Jahren (49.2 % weiblich) und untersuchte den prospektiven bidirektionalen Zusammenhang zwischen erlebter Gewichtsstigmatisierung und Gewichtsstatus anhand eines latenten Strukturgleichungsmodells über drei Messzeitpunkte hinweg. Die anderen beiden Publikationen beziehen sich auf eine Stichprobe mit Kindern und Jugendlichen im Alter zwischen 6 und 11 Jahren (51.1 % weiblich). Die zweite Publikation analysierte anhand einer hierarchischen Regression, welche intrapersonalen Risikofaktoren das internalisierte Gewichtsstigma prospektiv prädizieren. Die dritte Publikation untersuchte anhand von ROC-Kurven, ab welchem Ausmaß das internalisierte Gewichtsstigma mit einem erhöhten Risiko für psychosoziale Auffälligkeit und gestörtes Essverhalten einhergeht. Im Rahmen der ersten Publikation zeigte sich, dass ein höherer Gewichtsstatus mit einer höheren späteren Gewichtsstigmatisierung einhergeht und umgekehrt die Gewichtsstigmatisierung auch den späteren Gewichtsstatus prädiziert. Die zweite Publikation identifizierte Gewichtsstatus, gewichtsbezogene Hänseleien, depressive Symptome, Körperunzufriedenheit, Relevanz der eigenen Figur sowie das weibliche Geschlecht und einen niedrigeren Bildungsabschluss der Eltern als Prädiktoren des internalisierten Gewichtsstigmas. Die dritte Publikation verdeutlichte, dass das internalisierte Gewichtsstigma bereits ab einem geringen Ausmaß mit einem erhöhten Risiko für gestörtes Essverhalten einhergeht und mit weiteren psychosozialen Problemen assoziiert ist. Insgesamt zeigte sich, dass sowohl das erlebte als auch das internalisierte Gewichtsstigma bei Kindern und Jugendlichen über alle Gewichtsgruppen hinweg relevante Konstrukte sind, die im Entwicklungsverlauf ein komplexes Gefüge bilden. Es wurde deutlich, dass es essentiell ist, bidirektionale Wirkmechanismen einzubeziehen. Die vorliegende Dissertation liefert erste Ansatzpunkte für die Gestaltung von Präventions- und Interventionsmaßnahmen, um ungünstige Entwicklungsverläufe in Folge von Gewichtsstigmatisierung und internalisiertem Gewichtsstigma zu verhindern.
... To date, several studies in young people have demonstrated that experiencing weight stigma is a risk factor for poor psychosocial and behavioral health outcomes, such as higher prevalence of depressive symptoms [18][19][20], substance use [21], body dissatisfaction [18,22], disordered eating behaviors [15,17,[23][24][25][26], self-harm [18], social isolation [27], school avoidance [28], and low selfesteem [18,20,29,30]. In addition, studies have found that weight stigma, above and beyond any effects of baseline weight status, is a risk factor for future weight gain [25,[31][32][33][34]. ...
... Findings that weight teasing was associated with higher BMI cross-sectionally during adolescence, cross-sectionally during young adulthood, and longitudinally are consistent with our hypothesis and previous literature [25, [31][32][33][34]. Because of our large, diverse study population and longitudinal design, findings strengthen previous evidence that weight stigma is a risk factor for elevated weight status. ...
Article
Full-text available
Abstract Background Weight stigma is prevalent among young people and harmful to health. The current study used a health equity lens to examine cross-sectional and longitudinal associations between experiencing weight teasing (a form of weight stigma) with a range of weight-related health behaviors and weight status in an ethnically/racially and socioeconomically diverse sample of young people. We also assessed whether ethnicity/race and adolescent socioeconomic status (SES) operated as effect modifiers in these relationships. Methods Adolescents (n = 1568) were enrolled in EAT 2010–2018 (Eating and Activity over Time) and followed into young adulthood. Weight teasing; screen time; moderate-to-vigorous physical activity (MVPA); sleep duration; breakfast frequency; fruit, vegetable, sugar-sweetened beverage (SSB), and fast-food intake; and body mass index (BMI) were assessed at baseline (mean age = 14.4 years) and eight-year follow-up (mean age = 22.2 years). Multivariate linear regression estimated marginal means and 95% confidence intervals. All analyses adjusted for BMI and sociodemographic characteristics. Results Weight teasing was cross-sectionally associated with longer screen time, shorter sleep duration, and higher BMI during adolescence; and cross-sectionally associated with shorter sleep duration, lower breakfast frequency, higher fast-food intake, higher SSB intake, and higher BMI during young adulthood. In the longitudinal analyses, weight teasing was not associated with health behaviors but did predict higher BMI (teased: 28.2 kg/m2, not teased: 26.4 kg/m2, p
... A recent meta-analysis reported similar cross-sectional correlations between BMI and weight stigma across genders [4]. With regard to prospective studies, three studies did not observe gender differences with regard to the effect of weight-related stigma on weight [11,14] or vice versa [15]. Contrary, other studies reported that previous experience of weight stigma came along with a higher risk for obesity in girls, but not in boys [16], and that the predictive effect of weight stigma for BMI was higher among girls compared to boys [17]. ...
... Beyond that, it should be mentioned that we did not observe gender-related differences with respect to the relationship between weight-related stigma and BMI-SDS-neither cross-sectional nor longitudinal. This is in line with previous studies that also reported no gender differences [14,15], but runs contrary to others indicating that there might be gender differences [16,17]. A closer examination reveals that moderators might explain inconsistent results regarding gender differences. ...
Article
Full-text available
Many children and adolescents are confronted with weight stigma, which can cause psychological and physical burden. While theoretical frameworks postulate a vicious cycle linking stigma and weight status, there is a lack of empirical evidence. The aim was to analyze the longitudinal bidirectional relationship between body weight and weight stigma among children and adolescents. The sample consisted of 1381 children and adolescents, aged 9–19 years at baseline (49.2% female; 78% normal weight), from a prospective study encompassing three measurement points over 6 years. Participants provided self-reported data on experienced weight-related teasing and weight/height (as indicators for weight status). Latent structural equation modelling was used to examine the relationship between weight-related teasing experiences and weight. Additionally, gender-related differences were analyzed. Between the first two waves, there was evidence for a bidirectional relationship between weight and weight-related teasing. Between the last two waves, teasing predicted weight, but there was no reverse association. No gender-related differences were found. The data indicate a reciprocal association between weight stigma and body weight across weight groups and independent of gender. To prevent vicious cycles, approaches that simultaneously promote healthy weight and reduce weight stigma are required.
... Despite the high prevalence of weight stigma overall, certain characteristics and social identities can heighten vulnerability to such negative experiences. For example, from an early age, youth with higher weight are more likely than their peers with "normal" weight to experience both generalized (Morales et al., 2019;Waasdorp et al., 2018) and weightbased victimization or discrimination (Bucchianeri et al., 2016;Juvonen et al., 2017;Koyanagi et al., 2020;Schvey et al., 2019). Populations with elevated rates of overweight and obesity-including sexual and/or gender minorities (SGM; Grammer et al., 2019), youth from marginalized racial/ethnic groups , and those from lower socioeconomic status (SES; Williams et al., 2018)can in turn be at greater risk of experiencing weight stigma. ...
Article
Weight-based disparities in mental health impair the well-being of youth with overweight and obesity, who comprise a growing majority of young people in the United States. This review summarizes research regarding the extent of weight-based disparities in youth mental health and describes the social underpinnings of these disparities across contexts. Youth with high weight face frequent stigmatization (e.g., bullying, victimization, negative judgment), particularly in the school setting. Weight-based disparities in youth mental health emerge not because of high body weight itself, but because of the stigma associated with having high body weight. As such, policy actions need to address weight stigma. Empirical evidence can inform sound policies to reduce the stigma experienced by youth with high weight in order to support equitable mental health outcomes for youth with diverse body sizes.
... Therefore, understanding whether eating and weight-related concerns precede the use of WRSM apps is an important first step in understanding who uses WRSM apps and why, as well as understanding the temporality of relationships between eating and weight concerns and WRSM app use. Further, because eating and weight-related concerns are more common among individuals with higher BMIs, and WRSM is often recommended clinically for weight loss among those with higher BMIs, we wanted to explore the extent to which BMI may explain associations between eating and weightrelated concerns and later WRSM app use [25][26][27]. ...
Article
Full-text available
Purpose This study was designed to examine (1) the types of technologies or other applications (apps) emerging adults use to track their eating, physical activity, or weight; (2) who uses these apps and (3) whether eating and weight-related concerns during adolescence predict app use in emerging adulthood. Methods Longitudinal survey data were obtained from EAT 2010–2018 (Eating and Activity over Time study, N = 1428), a population-based sample of ethnically/racially and socioeconomically diverse adolescents (mean age: 14.5 ± 2.0 years), who were followed into emerging adulthood (mean age: 22.0 ± 2.0 years). Data were used to examine sociodemographic correlates of physical activity- and dietary-focused app use. Adjusted, gender-stratified logistic regressions were used to investigate longitudinal relationships between eating and weight-related concerns in adolescence and app use in emerging adulthood. Results Compared to men, women were more likely to use physical activity- (23.2 versus 12.5%, p < 0.001) and dietary-focused apps (16.1 versus 5.5%, p < 0.001). Among women, eating and weight-related concerns in adolescence, particularly unhealthy muscle-building behaviors (OR = 1.73, 95% CI 1.03–2.92), were associated with later dietary-focused app use. Among men, use of other muscle-building behaviors and body dissatisfaction in adolescence predicted use of physical activity- (ORother muscle-building = 1.60, 95% CI 1.03–2.49 and ORbody dissatisfaction = 1.67, 95% CI 1.06–2.65) and dietary-focused (ORother muscle-building = 2.18, 95% CI 1.07–4.47 and ORbody dissatisfaction = 2.35, 95% CI 1.12–4.92) apps 8 years later. Conclusions Eating and weight-related concerns may predict later use of physical activity- and dietary-focused apps; future research is needed to understand whether use of such apps further increases eating and weight-related concerns. Level of evidence III, well-designed longitudinal cohort study.
... The implications of obesity in physical health (cardiovascular diseases, diabetes, etc.) are well known, but recently, research has also focused on its impact on mental health (self-esteem, depression, etc.). In the last decade, and related to the increase in child obesity mentioned above, its implications for development have been considered as it seems to affect several domains of personal and social adjustment [3], and has also been related to some mental health conditions (anxiety, low self-esteem, conduct problems, etc.) [4][5][6]. Nevertheless, most studies have been carried out in children over 8 years of age, so we still have little information on what influences obesogenic behaviours in earlier ages. ...
Article
Full-text available
The purpose of our research was to explore the role of both parents’ use of behavioural regulation with food and children’s emotional self-regulation in young children with and without overweight/obesity. For this purpose, 123 participants (n = 62 boys and n = 61 girls) were recruited and classified into two groups by their Body Mass Index (BMI, non-overweight vs. overweight/obese) and into two age groups (four years and seven years). The children’s parents/primary caregivers completed two scales of the Childhood Obesogenic Behaviours’ Questionnaire (COBQ). The participants were measured and weighed to calculate their BMI to identify overweight, obesity, and non-overweight. The results showed that the means for children who were obese/overweight were significantly higher than those of children who were non-overweight for both the parents’ behavioural regulation scale (non-overweight: M = 1.80, SD = 0.69; overweight/obesity: M = 2.94, SD = 0.85) and the child’s emotional overeating scale (non-overweight: M = 1.47, SD = 0.56; overweight/obesity: M = 2.65, SD = 0.87). No statistically significant differences were found related to age (4 and 7 years), indicating that the potential impact of obesogenic behaviours starts early in development. Similarly, no differences by gender were found. Due to the implications of obesity for physical and mental health, and the high probability of maintaining this overweight status in the long term, family-based interventions to prevent obesity are highly advisable from birth.
Chapter
In this chapter, the authors provide an overview of the most prominent social consequences for adults and youth with obesity due to weight bias; summarize recent research on the impact of weight stigma on health, and identify promising avenues for preventing and reducing weight stigma. Through multiple pathways across institutional, interpersonal, and intrapersonal domains, stigma facilitates social and health inequities. The authors highlight two prominent domains in which weight stigma contributes to these disparities among adults with obesity: employment and health care. The anticipation, experience, and internalization of weight discrimination and stigmatization have profound effects on the mental and physical health of adults and youth with obesity. As stigma may occur at institutional, interpersonal, or intrapersonal levels, interventions can also be designed to target stigma at each of these levels.
Article
Objective Over the past two decades, there has been a steady increase in research focused on the association between weight-based stigma and mental health outcomes in children and adolescents. The present study is a systematic review and meta-analysis of the associations between weight stigma and mental health in youth. Methods A systematic search of PubMed, PsychInfo, and Embase databases was conducted in January 2020. Inclusion criteria included the following: (a) examined an association between weight stigma and a mental health outcome, (b) mean sample age <18 (+1 standard deviation) years, (c) written in English, and (d) peer reviewed. Forty eligible articles were identified. The moderating effects of age, sex (percent female), weight status (percent with overweight/obesity), and study quality were examined. Results Overall, meta-analytic findings using a random-effects model indicated a statistically significant moderate association between weight stigma and poorer mental health outcomes (r = .32, 95% confidence interval [0.292, 0.347], p < .001). Age and study quality each moderated the association between weight stigma and mental health. Generally, the study quality was fair to poor, with many studies lacking validated measurement of weight stigma. Conclusions Although there was a significant association between weight stigma and mental health in youth, study quality hinders the current body of literature. Furthermore, findings highlight the lack of consideration of internalized weight stigma in child populations, the importance of using validated measures of weight stigma, and the need for increased awareness of how these associations affect populations of diverse backgrounds.
Article
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Article
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Article
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Objectives To assess weight-related concerns and behaviors in a population-based sample of adolescents and to compare these concerns and behaviors across sex and weight status.Design The study population included 4746 adolescents from St Paul or Minneapolis, Minn, public schools who completed surveys and anthropometric measurements as part of Project EAT (Eating Among Teens), a population-based study focusing on eating patterns and weight concerns among teenagers.Main Outcome Measures Measured weight status, weight-related concerns (perceived weight status, weight disparity, body satisfaction, and care about controlling weight), and weight-related behaviors (general and specific weight control behaviors and binge eating).Results Weight-related concerns and behaviors were prevalent among the study population. Although adolescents were most likely to report healthy weight control behaviors (adolescent girls, 85%; and adolescent boys, 70%), also prevalent were weight control behaviors considered to be unhealthy (adolescent girls, 57%; and adolescent boys, 33%) or extreme (adolescent girls, 12%; and adolescent boys, 5%). Most overweight youth perceived themselves as overweight and reported the use of healthy weight control behaviors during the past year. However, the use of unhealthy and extreme weight control behaviors and binge eating were alarmingly high among overweight youth, particularly adolescent girls. Extreme weight control practices (taking diet pills, laxatives, or diuretics or vomiting) were reported by 18% of very overweight adolescent girls, compared with 6% of very overweight adolescent boys (body mass index, ≥95th percentile).Conclusion Prevention interventions that address the broad spectrum of weight-related disorders, enhance skill development for behavioral change, and provide support for dealing with potentially harmful social norms are warranted in light of the high prevalence and co-occurrence of obesity and unhealthy weight-related behaviors.
Article
Purpose: Weight stigma is implicated in disordered eating, but much of this research focuses on forms of stigma such as weight-based teasing. Methods: In a large cohort of adolescent girls (N = 2,036), we tested the hypothesis that being labeled as "too fat" by others predicts subsequent greater disordered eating cognitions and behaviors. Results: Compared with girls who did not report weight labeling, girls who were labeled at age 14 showed an increase in unhealthy weight control behaviors and disordered eating cognitions over the subsequent 5 years. These effects were independent of objective body mass index, race, parental income and education, and initial levels of disordered eating. Conclusions: Exploratory analyses suggest that weight labeling from family members is more strongly associated with disordered eating than labeling from nonfamily members. This study highlights how the long-term consequences of weight stigma can potentially begin when one is labeled as "too fat."
Article
Weight-based teasing is common among youth, but little is known about its long-term impact on health outcomes. We aimed to 1) identify whether weight-based teasing in adolescence predicts adverse eating and weight-related outcomes 15 years later; and 2) determine whether teasing source (peers or family) affects these outcomes. Data were collected from Project EAT-IV (Eating and Activity in Teens and Young Adults) (N = 1830), a longitudinal cohort study that followed a diverse sample of adolescents from 1999 (baseline) to 2015 (follow-up). Weight-based teasing at baseline was examined as a predictor of weight status, binge eating, dieting, eating as a coping strategy, unhealthy weight control, and body image at 15-year follow-up. After adjusting for demographic covariates and baseline body mass index (BMI), weight-based teasing in adolescence predicted higher BMI and obesity 15 years later. For women, these longitudinal associations occurred across peer and family-based teasing sources, but for men, only peer-based teasing predicted higher BMI. The same pattern emerged for adverse eating outcomes; weight-based teasing from peers and family during adolescence predicted binge eating, unhealthy weight control, eating to cope, poor body image, and recent dieting in women 15 years later. For men, teasing had fewer longitudinal associations. Taken together, this study shows that weight-based teasing in adolescence predicts obesity and adverse eating behaviors well into adulthood, with differences across gender and teasing source. Findings underscore the importance of addressing weight-based teasing in educational and health initiatives, and including the family environment as a target of anti-bullying intervention, especially for girls.
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Objective: To examine associations between perceived weight discrimination and changes in weight, waist circumference, and weight status. Methods: Data were from 2944 men and women aged ≥50 years participating in the English Longitudinal Study of Ageing. Experiences of weight discrimination were reported in 2010-2011 and weight and waist circumference were objectively measured in 2008-2009 and 2012-2013. ANCOVAs were used to test associations between perceived weight discrimination and changes in weight and waist circumference. Logistic regression was used to test associations with changes in weight status. All analyses adjusted for baseline BMI, age, sex, and wealth. Results: Perceived weight discrimination was associated with relative increases in weight (+1.66 kg, P < 0.001) and waist circumference (+1.12 cm, P = 0.046). There was also a significant association with odds of becoming obese over the follow-up period (OR = 6.67, 95% CI 1.85-24.04) but odds of remaining obese did not differ according to experiences of weight discrimination (OR = 1.09, 95% CI 0.46-2.59). Conclusions: Our results indicate that rather than encouraging people to lose weight, weight discrimination promotes weight gain and the onset of obesity. Implementing effective interventions to combat weight stigma and discrimination at the population level could reduce the burden of obesity.
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This prospective study examined age of onset for binge eating and purging among girls during late adolescence and tested whether dieting and negative affectivity predicted these outcomes. Of initially asymptomatic adolescents, 5% reported onset of objective binge eating, 4% reported onset of subjective binge eating, and 4% reported onset of purging. Peak risk for onset of binge eating occurred at age 16, whereas peak risk for onset of purging occurred at age 18. Adolescents more often reported onset of a single symptom rather than multiple symptoms, and symptoms were episodic. Dieting and negative affectivity predicted onset of binge eating and purging. Findings suggest that late adolescence is a high-risk period for onset of bulimic behaviors and identify modifiable risk factors for these outcomes.
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This article proposes that binge eating is motivated by a desire to escape from self-awareness. Binge eaters suffer from high standards and expectations, especially an acute sensitivity to the difficult (perceived) demands of others. When they fall short of these standards, they develop an aversive pattern of high self-awareness, characterized by unflattering views of self and concern over how they are perceived by others. These aversive self-perceptions are accompanied by emotional distress, which often includes anxiety and depression. To escape from this unpleasant state, binge eaters attempt the cognitive response of narrowing attention to the immediate stimulus environment and avoiding broadly meaningful thought. This narrowing of attention disengages normal inhibitions against eating and fosters an uncritical acceptance of irrational beliefs and thoughts. The escape model is capable of integrating much of the available evidence about binge eating.