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Adverse Childhood Experiences Associated with Greater Internalization of Weight Stigma in Women with Excess Weight

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Adverse childhood experiences (ACEs) may be an early life factor associated with adult weight stigma via biological (e.g., stress response), cognitive (e.g., self-criticism/deprecation), and/or emotional (e.g., shame) mechanisms. This pilot study investigated relationships between ACEs and internalized and experienced weight stigma in adult women with overweight/obesity and explored differential relationships between weight stigma and ACE subtypes (i.e., abuse, neglect, household dysfunction). Adult women (68% white, Mage = 33 ± 10 years, MBMI = 33.7 ± 7.2 kg/m2) completed measures of ACEs (ACE Questionnaire), internalized weight stigma (IWS; Weight Bias Internalization Scale—Modified; WBIS—M), and lifetime experiences of weight stigma (yes/no). Data were analyzed with linear and logistic regression (n = 46), adjusting for age, race, and body mass index (BMI). Linear regressions revealed a positive association between ACE and WBIS—M scores (β = 0.40, p = 0.006), which was driven by Abuse-type ACEs (β = 0.48, p = 0.009). Relationships between WBIS—M scores and Neglect- and Household-Dysfunction-type ACEs did not reach significance (β = 0.20, p = 0.173; β = −0.16, p = 0.273). Though descriptive statistics revealed greater rates of experienced weight stigma endorsement by those with high-3+ ACEs (81%) vs. medium-1–2 ACEs (67%) or low/no-0 ACEs (60%), ACE scores were not significantly associated with experienced weight stigma in logistic regression (Wald = 1.36, p = 0.244, OR = 1.324, 95%, CI = 0.825–2.125). ACEs may be an early life factor that increase the risk for internalizing weight stigma in adulthood. Larger studies should confirm this relationship and follow-up on descriptive findings suggesting a potential association between ACEs and experienced weight stigma.
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Brief Report
Adverse Childhood Experiences Associated with Greater
Internalization of Weight Stigma in Women with Excess Weight
Natalie G. Keirns 1, * , Cindy E. Tsotsoros 1, Samantha Addante 1, Harley M. Layman 1, Jaimie Arona Krems 1,
Rebecca L. Pearl 2,3 , A. Janet Tomiyama 4and Misty A.W. Hawkins 1


Citation: Keirns, N.G.; Tsotsoros,
C.E.; Addante, S.; Layman, H.M.;
Krems, J.A.; Pearl, R.L.; Tomiyama,
A.J.; Hawkins, M.A.W. Adverse
Childhood Experiences Associated
with Greater Internalization of Weight
Stigma in Women with Excess Weight.
Obesities 2021,1, 49–57. https://
doi.org/10.3390/Obesities1010005
Academic Editors: Janet D Latner,
Kerry O'Brien and Angela Meadows
Received: 23 April 2021
Accepted: 31 May 2021
Published: 3 June 2021
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Copyright: © 2021 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).
1
Department of Psychology, Oklahoma State University, 116 Psychology Building, Stillwater, OK 74078, USA;
cindy.tsotsoros@okstate.edu (C.E.T.); saddant@okstate.edu (S.A.); hlayman@okstate.edu (H.M.L.);
jaimie.krems@okstate.edu (J.A.K.); misty.hawkins@okstate.edu (M.A.W.H.)
2Department of Clinical and Health Psychology, University of Florida, 1225 Center Drive,
Gainesville, FL 32610, USA; rebecca.pearl@ufl.edu
3Center for Weight and Eating Disorders, Department of Psychiatry, Perelman School of Medicine,
University of Pennsylvania, 3535 Market Street, Suite 3108, Philadelphia, PA 19104, USA
4Department of Psychology, University of California, A623 Franz Hall, 501 Portola Plaza,
Los Angeles, CA 90095, USA; tomiyama@psych.ucla.edu
*Correspondence: natalie.keirns@okstate.edu
Abstract:
Adverse childhood experiences (ACEs) may be an early life factor associated with adult
weight stigma via biological (e.g., stress response), cognitive (e.g., self-criticism/deprecation), and/or
emotional (e.g., shame) mechanisms. This pilot study investigated relationships between ACEs and
internalized and experienced weight stigma in adult women with overweight/obesity and explored
differential relationships between weight stigma and ACE subtypes (i.e., abuse, neglect, household
dysfunction). Adult women (68% white, M
age
= 33
±
10 years, M
BMI
= 33.7
±
7.2 kg/m
2
) completed
measures of ACEs (ACE Questionnaire), internalized weight stigma (IWS; Weight Bias Internalization
Scale—Modified; WBIS—M), and lifetime experiences of weight stigma (yes/no). Data were analyzed
with linear and logistic regression (n= 46), adjusting for age, race, and body mass index (BMI). Linear
regressions revealed a positive association between ACE and WBIS—M scores (
β
= 0.40, p= 0.006),
which was driven by Abuse-type ACEs (
β
= 0.48, p= 0.009). Relationships between WBIS—M scores
and Neglect- and Household-Dysfunction-type ACEs did not reach significance (β= 0.20, p= 0.173;
β
=
0.16, p= 0.273). Though descriptive statistics revealed greater rates of experienced weight
stigma endorsement by those with high-3+ ACEs (81%) vs. medium-1–2 ACEs (67%) or low/no-0
ACEs (60%), ACE scores were not significantly associated with experienced weight stigma in logistic
regression (Wald = 1.36, p= 0.244, OR = 1.324, 95%, CI = 0.825–2.125). ACEs may be an early life
factor that increase the risk for internalizing weight stigma in adulthood. Larger studies should
confirm this relationship and follow-up on descriptive findings suggesting a potential association
between ACEs and experienced weight stigma.
Keywords:
weight stigma; internalized weight stigma; adverse childhood experiences; ACEs; child-
hood abuse; obesity
1. Introduction
Weight stigma, or the “social devaluation and denigration of people who are perceived
to carry excess weight [
1
]” is endemic to Western societies [
2
]. While weight stigma is
often directly experienced, it also may be internalized (i.e., applied to oneself); internalized
weight stigma (IWS) is characterized by self-devaluation based on weight [
3
]. Experiencing
and internalizing weight stigma is associated with consequences to both physical health
(i.e., poorer overall health, mortality risk) and psychological well-being (i.e., depression,
body dissatisfaction) [
1
,
4
7
]. Given these highly detrimental effects, it is imperative to
understand risk factors for both experiencing and internalizing weight stigma.
Obesities 2021,1, 49–57. https://doi.org/10.3390/Obesities1010005 https://www.mdpi.com/journal/obesities
Obesities 2021,150
One such risk factor may be adverse childhood experiences (ACEs)—chronic and
pervasive events that occur in childhood, including experiences of abuse, deprivation or
neglect, and household dysfunction [
8
]. The chronic stress of ACEs has been consistently
related to biological changes which increase appetite and visceral fat accumulation, and
ACEs are a well-established risk factor for both the development of adult obesity and for
increasing severity of adult obesity levels [
9
,
10
]. Thus, these factors may put individuals
with ACEs at risk for experiencing more weight stigma [
11
]. Furthermore, ACEs—and
particularly experiences of childhood abuse—are linked to attention biases for threatening
information [
12
], which could impact how individuals identify and perceive stigmatizing
experiences when they are encountered. In other words, ACEs history may increase the
likelihood that an individual will recognize instances of discriminatory or unfair weight-
based treatment and identify them as stigmatizing. Still further, like weight stigma, ACEs
are linked to the use of unhelpful coping strategies specific to eating (e.g., binge eating) and
negative cognitive and emotional patterns, such as tendencies toward self-criticism and
shame [
10
,
13
17
]. As self-criticism and shame center on negative self-evaluation, they are
closely related to devaluing oneself based on weight or IWS [
18
21
]. Therefore, a proposed
negative cycle may develop in which individuals experiencing ACEs are more likely to
have greater obesity and consequent risk for experienced weight stigma. They may also
be more likely to identify these stigmatizing experiences and to engage in maladaptive,
obesogenic coping behaviors when under stress. Maladaptive coping responses and/or
other’s criticisms may intersect with a tendency toward self-critical thoughts and feelings of
shame, which may manifest as IWS, further exacerbate stress levels, and lead to continued
maladaptive coping strategies and potential weight gain. Importantly, in this cycle, the
development of IWS can be independent of both objective obesity and experienced weight
stigma, as IWS is driven by self-perceived weight and self-application of weight-based
stereotypes, and, therefore, can occur in the absence of excess weight and/or experienced
weight stigma.
The hypotheses inherent to this cyclical model have not yet been tested, but prelimi-
nary evidence supports the proposed associations between ACEs and weight stigma. A
small number of studies have identified a link between ACEs—and/or childhood mal-
treatment more generally—and weight stigma in adulthood [
18
,
19
,
22
]. Udo and Grilo [
22
]
found that women with a history of childhood maltreatment (i.e., abuse or neglect) were
more likely to report experiencing weight-based discrimination in the past year, and
Braun et al.
[
18
,
19
] observed positive correlations between ACEs and both experienced
and internalized weight stigma in bariatric surgery patients. However, no study to date
has investigated whether ACEs are robustly associated with IWS in broader populations
or after considering related covariates (e.g., BMI). Understanding whether or not objec-
tive obesity level impacts the relationship between ACEs and weight stigma is important
because—as mentioned above—many negative effects of weight stigma are linked to
one’s self-perceived weight status and can occur in the absence of objectively measured
overweight/obese BMI [23].
It is additionally unknown whether there may be differential associations of ACE types
(i.e., abuse, neglect, household dysfunction) with weight stigma, as there is some evidence
of abuse and neglect-type ACEs being more detrimental than household dysfunction for
adult outcomes [
24
]. For instance, there is a more robust literature linking childhood
abuse to feelings of shame in adulthood compared to the other ACE subtypes [
25
29
]. This
evidence base may implicate pathways that contribute to the proposed relationship between
ACEs and IWS by way of abuse leading to self-deprecation or negative self/body image.
The current pilot study takes initial steps in filling these gaps regarding the ACEs–
weight stigma relationship by providing a preliminary investigation of the following two
aims: (1) to explore whether a history of ACEs is associated with internalization of weight
stigma, and (2) to explore whether a history of ACEs is associated with lifetime experiences
of weight stigma. Secondary objectives include exploring potential differential associations
Obesities 2021,151
of ACE types (e.g., abuse, neglect, household dysfunction) on internalized or experienced
weight stigma.
2. Materials and Methods
2.1. Participants
Participants were adult women with overweight/obesity enrolled in the Neurotrophic
Indicators of Cognition, Executive Skills, Plasticity, and Adverse Childhood Experiences
Study (NICE SPACES), a pilot project examining weight, neurocognitive health, and stress
reactivity in women with and without a history of ACEs (ClinicalTrials.gov, accessed
on 2 June 2021, Identifier: NCT04076722). The primary aims of NICE SPACES were
to assess the roles of brain health and ACEs in stress reactivity among women with
excess adiposity. Participants were recruited from the university campus and surrounding
community via email and social media. Participants with high (3+) and low/no (0) ACEs
were preferentially recruited to increase ACEs variability, but individuals of all ACE levels
were enrolled in the study, including “medium” ACE levels (1–2 ACEs). Eligibility criteria
relevant to the current project include the following: (1) BMI
25 kg/m
2
, (2) English-
speaking, (3) no use of weight-loss medications in the past 3 months, (4) no history of
bariatric surgery, (5) not currently pregnant or breastfeeding, (6) not currently enrolled in a
weight-loss program, and (7) no significant medical or psychiatric comorbidities.
2.2. Measures
2.2.1. Adverse Childhood Experiences (ACEs)
An expanded version of the Adverse Childhood Experiences Questionnaire was used
to assess the occurrence of ACEs prior to participants’ eighteenth birthday [
8
,
30
]. This
ACE Questionnaire assesses for the 10 traumatic childhood events identified by Felitti and
colleagues [
8
] (i.e., physical, emotional, or sexual abuse (Abuse-type ACEs); emotional
or physical neglect (Neglect-type ACEs); parental separation/divorce; parental domestic
violence; parental incarceration; drug or alcohol use in the household; or mental illness or
attempted suicide in the household (Household Dysfunction-type ACEs)) with 17 yes/no
questions, resulting in possible total scores ranging from 0–17. This expanded, 17-item
measure allows for a more nuanced assessment of the standard 10 ACEs. For example, the
traditional questionnaire assesses for emotional abuse with one item asking, “Did a parent
or other adult in the household often or very often push grab, slap, or throw something at
you? Or ever hit you so hard that you had marks or were injured?” whereas the 17-item
measure breaks this into two questions: “Did a parent or other adult in the household
often push, grab, slap, or throw something at you?” and “Did a parent or other adult in the
household ever hit you so hard that you had marks or were injured?” Additionally, unique
effects of the three subtypes of ACEs (i.e., abuse, neglect, household dysfunction) [
31
]
were explored. A list of the expanded ACEs Questionnaire items and their groupings into
subscales can be found in Supplementary Materials: Table S1.
2.2.2. Internalized Weight Stigma (IWS)
The Weight Bias Internalization Scale—Modified (WBIS—M) was used to measure
IWS [
32
,
33
]. The WBIS—M consists of 11 items that measure the extent to which individuals
apply negative stereotypes to and devalue themselves because of their weight (e.g., “My
weight is a major way that I judge my value as a person”). Response options range from
1 (Strongly Disagree)to7(Strongly Agree), and scores are represented by a mean of all
responses. Higher average scores are indicative of greater internalization of weight stigma.
In the current study, the WBIS—M displayed good reliability (
α
= 0.85), similar to the
findings of the original validation sample (α= 0.94) [32].
2.2.3. Experienced Weight Stigma
To assess whether participants had ever experienced weight stigma, questions were
adapted from Puhl, Luedicke, and Heuer (2011) [
34
]. In a series of three questions, par-
Obesities 2021,152
ticipants were asked to indicate (yes/no) if they had ever been teased, treated unfairly, or
discriminated against because of their weight. Responses of “yes” were coded as 1 and
responses of “no” were coded as 0. Paralleling previous literature, a dichotomous measure
of whether participants had ever experienced weight stigma was calculated as 1 (“yes” on
at least one of the three items) or 0 (“no” to all three items) [35,36].
2.2.4. Covariates
Measured BMI and demographic variables (i.e., age, race) were included as covariates.
BMI was calculated as kg/m
2
from height and weight measured using a research-grade
TANITA body composition analyzer. Demographic factors were collected via an online
self-report questionnaire. Race was coded as follows: 1 = American Indian/Alaska Native,
2 = Asian, 3 = Native Hawaiian or Other Pacific Islander, 4 = Non-Hispanic Black or African
American, 5 = Non-Hispanic White, 6 = White—Hispanic, 7 = Multiracial. Due to insuffi-
cient representation in each group, racial categories were dummy coded as
0 = historically
oppressed/marginalized racial group and 1 = non-Hispanic white for analyses.
2.3. Procedure
All participants completed an online pre-screener survey in order to qualify for the
study. Following enrollment, participants completed an at-home online survey and a 3 h
in-lab assessment and were compensated 60 USD. ACEs, demographic variables, IWS, and
lifetime-experienced weight stigma were assessed via online surveys. BMI was measured
in-lab by a trained research assistant. All procedures were approved by the university’s
IRB and adhered to APA ethical guidelines. Participants provided informed consent prior
to study initiation.
2.4. Data Analysis Plan
All data were verified and checked for normality prior to analyses. Study aims were
analyzed using linear or logistic regression. ACE subtype scores were entered simultane-
ously into regression models and multicollinearity checks (tolerance > 0.1, VIF < 10) were
conducted to ensure the appropriateness of each model. Covariates in all analyses were
age, race, and BMI; any non-significant covariates were retained in final models due to
theoretical justification for their inclusion. All analyses were conducted in SPSS Version 25.
3. Results
3.1. Participant Characteristics
A total of 53 women (68% white, M
age
= 33
±
10 years) enrolled in the study. All
women had a measured BMI in the overweight or obese range (
25.0 kg/m
2
,M
BMI
= 33.7
±
7.2 kg/m
2
). Among these participants, 51 responded to the ACE questionnaire: 11 (22%)
endorsed 0 ACEs, 17 (33%) endorsed 1 or 2 ACEs, and 23 (45%) endorsed 3 or more ACEs.
In the full sample, the most commonly endorsed ACE type was household dysfunction
(60.4%), followed by abuse (52.8%) and neglect (34.0%). An additional five participants
were excluded from analyses due to missing data on other key variables. Therefore, 46 par-
ticipants were included in the analyzed sample. Table 1includes participant characteristics
for the full sample and by ACE group status.
3.2. Aim 1: Internalized Weight Stigma
3.2.1. Total ACE Score
Linear regression was used to analyze whether ACEs total score was associated with
IWS, as measured by WBIS—M scores, after adjusting for covariates. The overall Step 2
model (including ACEs and covariates) was significant (F(4, 44) = 4.40, p= 0.005, R
2
= 0.305).
Having a higher number of ACEs was significantly associated with higher WBIS—M scores
(
β
= 0.40, p= 0.006), and ACE score explained 14.6% of the variance in WBIS—M scores.
Of the three covariates, only age was found to be significantly associated with WBIS—M
Obesities 2021,153
scores (
β
= 0.37, p= 0.008), suggesting that younger individuals report a greater degree of
IWS (see Table 2).
Table 1. Participant characteristics for the full sample and by ACE status.
ACE Status a
Total
Sample
(N= 53)
Low/No
0 ACE
(n= 11)
Medium
1–2 ACE
(n= 17)
High
3+ ACE
(n= 23)
pb
M±SD or n(%)
Demographic Factors & Covariates
Age (years) 33.19 ±10.0 33.18 ±11.2 29.94 ±8.3 33.74 ±10.1 0.314
BMI (kg/m2)33.70 ±7.2 32.35 ±7.3 34.93 ±7.9 32.89 ±5.9 0.563
Race/Ethnicity
0.198
Non-Hispanic white 36 (67.9) 10 (90.9) 12 (70.6) 14 (60.9)
Historically
marginalized/
oppressed racial group
17 (32.1) 1 (9.1) 5 (29.4) 9 (39.1)
Key Study Variables
WBIS—M (1–7) 4.59 ±0.9 4.11 ±1.0 4.49 ±0.9 4.83 ±0.9 0.108
Experienced Weight
Stigma (Y/N) 34 (70.8) 6 (60.0) 10 (66.7) 17 (81.0) 0.417
ACE Questionnaire
Total Score (0–17) 2.90 ±2.9 1.50 ±0.7 5.26 ±2.5 -
ACE Subtype
Frequency
Abuse 28 (52.8) 9 (52.9) 19 (82.6) 0.072
Neglect 18 (34.0) 2 (11.8) 15 (65.2) 0.001 *
Household
Dysfunction 32 (60.4) 9 (52.9) 22 (95.7) 0.001 *
Note. Continuous variables are presented as M(SD). Categorical variables presented as n(%).
a
Based on collapsed
10-item ACE scores. bprepresents differences between ACE status based on a one-way ANOVA for continuous
variables and a Chi-square for categorical variables. Only those with Medium and High ACEs were included in
Chi-squares for ACE subtypes. * Significant at p< 0.05.
trending toward significance at p< 0.15. ACE = Adverse
Childhood Experiences. WBIS—M = Weight Bias Internalized Scale—Modified.
3.2.2. ACE Type Subscale Scores
A second linear regression was conducted to explore differential relationships between
ACE-type subscales and IWS, as measured by WBIS—M scores. Multicollinearity checks
confirmed the appropriateness of simultaneously including ACE-type subscales in a single
model. Results indicated that the overall Step 2 model (including ACE types and covariates)
was significant (F(6, 44) = 4.66, p= 0.001, R
2
= 0.424). Altogether, the three ACE-type
subscales explained 26.5% of the variance in WBIS—M scores. However, the Abuse subscale
was the only ACE type to be uniquely and significantly associated with WBIS—M scores
(
β= 0.48,
p= 0.009). Associations between WBIS—M scores and Neglect (
β
= 0.20,
p= 0.173
)
or Household Dysfunction (
β
=
0.16, p= 0.273) did not reach significance. Younger age
was associated with higher WBIS—M scores (
β
=
0.41, p= 0.003); neither race nor BMI
displayed a significant relationship with WBIS—M scores. These results indicate that
individuals who experience abuse-type ACEs and younger individuals reported higher
levels of IWS (see Table 2).
3.3. Aim 2: Experienced Weight Stigma
3.3.1. Total ACE Score
To examine the association between ACEs history and experienced weight stigma, we
conducted a logistic regression with whether or not an individual had ever experienced
weight stigma (yes/no) as the dependent variable. Specifically, we evaluated if the total
number of ACEs was associated with the odds of experiencing weight stigma, adjusting
Obesities 2021,154
for age, race, and BMI. The overall Block 2 model (including ACEs and covariates) was
significant (
χ2
(4) = 16.55, p= 0.002), although ACE score was not a significant predictor
(Wald = 1.36, p= 0.244). That is, a higher ACE score was not associated with greater odds
of experiencing weight stigma (OR = 1.324, 95%CI = 0.825–2.125). However, a descriptive
pattern did emerge such that reported rates of lifetime experienced weight stigma were
higher in those with high-3+ ACEs (81%) versus medium—1–2 ACEs (67%) or low/no-0
ACEs (60%) (see Table 1).
Table 2. Associations of adverse childhood experiences with internalized weight stigma.
Model 1a
Total ACEs Predicting
WBIS—M Scores
(n= 46)
Model 1b
ACE-Type Subscales Predicting
WBIS—M Scores
(n= 46)
R2R2R2R2
Step 1 0.159 – 0.159 –
Step 2 0.305 0.146 * 0.424 0.265 *
βpβp
Age 0.373 * 0.008 0.407 * 0.003
Race/Ethnicity 0.181 0.190 0.252 0.059
BMI 0.218 0.106 00.166 0.191
Total ACE
Questionnaire Score 0.399 * 0.006 - -
ACEs—Abuse - - 0.477 * 0.009
ACEs—Neglect - - 0.203 0.173
ACEs—Household
Dysfunction - - 0.161 0.273
Note: * p< 0.05;
Only covariates (age, race/ethnicity, BMI) were entered on Step 1. For parsimony, specific beta co-
efficients of covariates are only presented for Step 2;
0 = oppressed/marginalized racial group,
1 = non-Hispanic
white; ACE = adverse childhood experience; ACEs—Abuse = emotional, physical, or sexual abuse subscale
score; ACEs—Neglect = emotional or physical neglect subscale score; ACEs—Household Dysfunction = mother
treated violently, substance abuse, or mental illness in the household, parental separation or divorce, or incar-
cerated household member subscale score; BMI = body mass index; WBIS—M = Weight Bias Internalization
Scale—modified.
3.3.2. ACE Type Subscale Scores
An analogous logistic regression analysis was conducted to evaluate whether ACE-
type subscale scores predicted the likelihood of experiencing weight stigma. Multicollinear-
ity checks confirmed the appropriateness of simultaneously including ACE-type subscales
in a single model. Logistic regression results indicated that although the overall Block
2 model (including ACE types and covariates) was significant (
χ2
(6) = 17.23, p= 0.008),
no ACE types were significantly associated with experienced weight stigma. Specifically,
Wald statistics for the three ACE type subscales were as follows: Abuse (
Wald = 0.03
,
p= 0.85
4), Neglect (Wald = 0.85, p= 0.356), and Household Dysfunction (Wald = 1.11,
p= 0.293
). Therefore, neither Abuse (OR = 0.913, 95%CI = 0.346–2.405), Neglect (
OR = 1.965
,
95%CI = 0.469–8.239
), nor Household Dysfunction (OR = 1.526, 95%CI = 0.694–3.356) was
associated with the odds that an individual had ever experienced weight stigma.
4. Discussion
In a pilot sample of women with overweight/obesity, having a higher number of
ACEs was associated with greater endorsement of internalized weight stigma (IWS). The
relationship between ACEs and IWS was driven predominantly by experiences of abuse.
Though associations between childhood adversity and the internalization of weight stigma
have not been thoroughly investigated, previous positive bivariate correlations between
ACEs and IWS have been observed [
18
,
19
]. The current study replicates and extends these
findings by observing that ACEs are predictive of IWS after adjustment for age, race, and
BMI. This study also adds to the evidence by showing that ACEs subtypes are differentially
Obesities 2021,155
associated with IWS, with abuse potentially driving the ACEs–IWS relationship. Childhood
physical, sexual, or emotional abuse often includes pervasive and unpredictable exposure
to an acute stressor, which may result in more toxic stress and increased allostatic load,
as well as having particular impacts on cognitive and emotional patterns (e.g., tendencies
toward self-deprecation and shame), as compared to the other ACE types [
12
,
37
]. A post
hoc sensitivity analysis exploring differences between abuse types (i.e., emotional, sexual,
physical) revealed differences such that emotional and sexual abuse were significantly
associated with greater IWS (
β
s = 0.380, 0.318; ps < 0.05), whereas physical abuse was not
(
β
= 0.031, p= 0.85) Additional research on the unique effects of each individual ACE and
their pathways to adverse outcomes for health and well-being throughout life is warranted.
The observed association between ACEs and IWS provides preliminary support for
the theorized cycle between ACEs, negative cognitive/emotional responses related to
shame/self-deprecation, and IWS. Based on this cycle, self-critical thoughts and feelings
of shame may be potential mechanisms between ACEs and IWS that warrant further
investigation. Emerging evidence has identified shame and (lack of) self-compassion as
factors that may mediate relationships between IWS and negative outcomes (e.g., emotional
eating, depression, anxiety), and negative self-evaluation has been proposed as a critical
maintaining factor in IWS [
13
,
14
,
18
20
]. Therefore, after confirming these mechanisms
with additional research, targeting these negative cognitive and affective patterns that can
develop after experiencing ACEs may be a particularly important point of intervention
for reducing the impact of early life adversity on IWS. Additionally, minimizing IWS for
persons with a history of ACEs is imperative for promoting their long-term health and
well-being. As some experts have suggested that IWS itself may be a chronic stressor [
38
],
evidence-based stress-reduction techniques such as mindfulness and mindfulness-based
therapies could be of particular relevance.
Of note, this pilot study did not observe significant relationships between ACEs
and lifetime weight stigma experiences. This null finding contrasts previous investiga-
tions documenting associations between childhood adversity and greater self-reported
frequency of experienced weight stigma [
18
,
19
,
22
]. Potential reasons for this discrepancy
include limited power and methodological differences compared to previous investigations
(
e.g., childhood
maltreatment vs. ACEs assessment, past-year weight discrimination vs.
lifetime weight stigma experiences). Of note, at the descriptive level, greater rates of expe-
rienced weight stigma were endorsed by those with high-3+ ACEs (81%) vs. medium-1–2
ACEs (67%), or low/no-0 ACEs (60%), which suggests that additional investigations in
larger samples are warranted.
Additional limitations that warrant follow-up include a relatively homogenous sam-
ple (i.e., adult, primarily white, treatment-seeking women with overweight/obesity),
which limits generalizability to the larger population (e.g., adolescents and young adults,
marginalized individuals). Further, with a small pilot sample, the current study is vul-
nerable to restriction of range in addition to lack of power. Over two-thirds (71%) of the
sample endorsed ever experiencing weight stigma, and this limited variability may have
further exacerbated difficulties achieving sufficient power to detect a significant effect of
ACEs history on weight-stigma experiences. However, these preliminary results justify
future, larger-scale studies with the resources to recruit larger, more diverse samples to
more thoroughly investigate relationships between early life stressors, such as ACEs, and
weight stigma.
In sum, the current study was a pilot investigation of ACEs and weight stigma in adult
women with overweight/obesity. Experiencing a greater number of ACEs in childhood was
associated with internalizing weight stigma to a greater degree in adulthood. This finding
highlights childhood adversity as an early life factor that may contribute to internalized
weight stigma in adulthood. Future research should confirm these relationships and
identify mechanisms between experiences of adversity in childhood and adult experiences
and the internalization of weight stigma.
Obesities 2021,156
Supplementary Materials:
The following are available online at https://www.mdpi.com/article/10
.3390/Obesities1010005/s1, Table S1: Adverse Childhood Experiences Questionnaire Subscale Items.
Author Contributions:
Conceptualization, N.G.K., J.A.K., A.J.T. and M.A.W.H.; Methodology, N.G.K.
and M.A.W.H.; Formal Analysis, N.G.K.; Investigation, N.G.K., C.E.T., S.A., H.M.L. and M.A.W.H.;
Resources, M.A.W.H.; Data Curation, N.G.K.; Visualization, N.G.K.; Writing—Original Draft Prepa-
ration, N.G.K., C.E.T., S.A. and H.M.L.; Writing—Review and Editing, N.G.K., C.E.T., S.A., H.M.L.,
J.A.K., R.L.P., A.J.T. and M.A.W.H.; Supervision, J.A.K., R.L.P., A.J.T. and M.A.W.H.; Project Ad-
ministration, N.G.K. and M.A.W.H.; Funding Acquisition, N.G.K. and M.A.W.H.; Software, N/A;
Validation, N/A. All authors have read and agreed to the published version of the manuscript.
Funding:
The authors disclosed receipt of the following financial support for the research, authorship,
and/or publication of this article: this work was supported by the National Heart, Lung, and Blood
Institute of the National Institutes of Health [F31HL152620, K23HL140176]; the National Institute
of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health [K23DK103941];
and by an Institutional Development Award (IDeA) from the National Institute of General Medical
Sciences of the National Institutes of Health [P20GM109097].
Institutional Review Board Statement:
The study was conducted according to the guidelines of
the Declaration of Helsinki, and approved by the Institutional Review Board of Oklahoma State
University (IRB# AS-19–65, approved 06–18–2019).
Informed Consent Statement:
Informed consent was obtained from all subjects involved in the study.
Data Availability Statement:
Data are not publicly available but interested parties may contact the
corresponding author for inquiries.
Conflicts of Interest: The authors declare no conflict of interest.
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... Crucially, for cisgender women of a higher body weights, averse childhood experiences have been found to be positively associated with greater internalisation of weight stigma (Keirns, Tsotsoros et al. 2021). Adverse childhood experiences may be an early life factor that increases vulnerability to adult weight stigma through biological (e.g., stress response), social (e.g., attachment insecurity, fear of negative evaluation, social anxiety), cognitive (e.g., self-criticism/depreciation, early maladaptive schemas, poor concept of self), and/or emotional (e.g., shame, lack of self-compassion, emotional dysregulation) mechanisms. ...
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