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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://
Academic Editors: Janet D Latner,
Kerry O'Brien and Angela Meadows
Received: 23 April 2021
Accepted: 31 May 2021
Published: 3 June 2021
Publisher’s Note: MDPI stays neutral
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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://
Department of Psychology, Oklahoma State University, 116 Psychology Building, Stillwater, OK 74078, USA; (C.E.T.); (S.A.); (H.M.L.); (J.A.K.); (M.A.W.H.)
2Department of Clinical and Health Psychology, University of Florida, 1225 Center Drive,
Gainesville, FL 32610, USA;
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;
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
= 33
10 years, M
= 33.7
7.2 kg/m
) 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 (
= 0.40, p= 0.006),
which was driven by Abuse-type ACEs (
= 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;
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.
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 [
]” is endemic to Western societies [
]. 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 [
]. 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) [
]. Given these highly detrimental effects, it is imperative to
understand risk factors for both experiencing and internalizing weight stigma.
Obesities 2021,1, 49–57.
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 [
]. 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 [
]. Thus, these factors may put individuals
with ACEs at risk for experiencing more weight stigma [
]. Furthermore, ACEs—and
particularly experiences of childhood abuse—are linked to attention biases for threatening
information [
], 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 [
]. As self-criticism and shame center on negative self-evaluation, they are
closely related to devaluing oneself based on weight or IWS [
]. 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 [
]. Udo and Grilo [
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.
] 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 [
]. For instance, there is a more robust literature linking childhood
abuse to feelings of shame in adulthood compared to the other ACE subtypes [
]. 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 (, 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) 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 [
]. This
ACE Questionnaire assesses for the 10 traumatic childhood events identified by Felitti and
colleagues [
] (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) [
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
]. 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 (
= 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) [
]. 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
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
= 33
10 years) enrolled in the study. All
women had a measured BMI in the overweight or obese range (
25.0 kg/m
= 33.7
7.2 kg/m
). 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
= 0.305).
Having a higher number of ACEs was significantly associated with higher WBIS—M scores
= 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 (
= 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
(N= 53)
(n= 11)
1–2 ACE
(n= 17)
3+ ACE
(n= 23)
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
Non-Hispanic white 36 (67.9) 10 (90.9) 12 (70.6) 14 (60.9)
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
Abuse 28 (52.8) 9 (52.9) 19 (82.6) 0.072
Neglect 18 (34.0) 2 (11.8) 15 (65.2) 0.001 *
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(%).
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
= 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 (
= 0.20,
p= 0.173
or Household Dysfunction (
0.16, p= 0.273) did not reach significance. Younger age
was associated with higher WBIS—M scores (
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 (
(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)
Step 1 0.159 – 0.159 –
Step 2 0.305 0.146 * 0.424 0.265 *
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
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
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 (
(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 [
]. 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 [
]. 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 (
s = 0.380, 0.318; ps < 0.05), whereas physical abuse was not
= 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 [
]. 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 [
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 [
]. 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
.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.
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.
Tomiyama, A.J. Weight stigma is stressful. A review of evidence for the Cyclic Obesity/Weight-Based Stigma model. Appetite
2014,82, 8–15. [CrossRef] [PubMed]
Rubino, F.; Puhl, R.M.; Cummings, D.E.; Eckel, R.H.; Ryan, D.; Mechanick, J.I.; Nadglowski, J.; Salas, X.R.; Schauer, P.R.;
Twenefour, D.; et al. Joint international consensus statement for ending stigma of obesity. Nat. Med.
,26, 485–497. [CrossRef]
Puhl, R.M.; Himmelstein, M.S.; Quinn, D.M. Internalizing Weight Stigma: Prevalence and Sociodemographic Considerations in
US Adults. Obesity 2018,26, 167–175. [CrossRef]
Hunger, J.M.; Major, B. Weight stigma mediates the association between BMI and self-reported health. Health Psychol.
34, 172–175. [CrossRef] [PubMed]
Hunger, J.M.; Major, B.; Blodorn, A.; Miller, C.T. Weighed Down by Stigma: How Weight-Based Social Identity Threat Contributes
to Weight Gain and Poor Health. Soc. Pers. Psychol. Compass 2015,9, 255–268. [CrossRef]
6. Puhl, R.M.; Heuer, C.A. The Stigma of Obesity: A Review and Update. Obesity 2009,17, 941–964. [CrossRef] [PubMed]
7. Pearl, R.L.; Puhl, R.M. Weight bias internalization and health: A systematic review. Obes. Rev. 2018,19, 1141–1163. [CrossRef]
Felitti, V.J.; Anda, R.F.; Nordenberg, D.; Williamson, D.F.; Spitz, A.M.; Edwards, V.; Koss, M.P.; Marks, J.S. Reprint of: Relationship
of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults: The Adverse Childhood
Experiences (ACE) Study. Am. J. Prev. Med. 2019,56, 774–786. [CrossRef]
Berens, A.E.; Jensen, S.K.G.; Nelson, C.A. Biological embedding of childhood adversity: From physiological mechanisms to
clinical implications. BMC Med. 2017,15, 1–12. [CrossRef]
Palmisano, G.L.; Innamorati, M.; Vanderlinden, J. Life adverse experiences in relation with obesity and binge eating disorder: A
systematic review. J. Behav. Addict. 2016,5, 11–31. [CrossRef]
Puhl, R.M.; Andreyeva, T.; Brownell, K.D. Perceptions of weight discrimination: Prevalence and comparison to race and gender
discrimination in America. Int. J. Obes. 2008,32, 992–1000. [CrossRef]
McLaughlin, K.A.; Sheridan, M.A.; Lambert, H.K. Childhood adversity and neural development: Deprivation and threat as
distinct dimensions of early experience. Neurosci. Biobehav. Rev. 2014,47, 578–591. [CrossRef]
Sachs-Ericsson, N.; Verona, E.; Joiner, T.; Preacher, K.J. Parental verbal abuse and the mediating role of self-criticism in adult
internalizing disorders. J. Affect. Disord. 2006,93, 71–78. [CrossRef] [PubMed]
Ratcliffe, D.; Ellison, N. Obesity and Internalized Weight Stigma: A Formulation Model for an Emerging Psychological Problem.
Behav. Cogn. Psychother. 2013,43, 239–252. [CrossRef]
Hankin, B.L.; Snyder, H.R.; Gulley, L.D.; Schweizer, T.H.; Bijttebier, P.; Nelis, S.; Toh, G.; Vasey, M. Understanding comorbidity
among internalizing problems: Integrating latent structural models of psychopathology and risk mechanisms. Dev. Psychopathol.
2016,28, 987–1012. [CrossRef]
Obesities 2021,157
Thomson, P.; Jaque, S.V. History of childhood adversity and coping strategies: Positive flow and creative experiences.
Child Abus. Negl. 2019,90, 185–192. [CrossRef] [PubMed]
Wojcik, K.D.; Cox, D.W.; Kealy, D. Adverse childhood experiences and shame- and guilt-proneness: Examining the mediating
roles of interpersonal problems in a community sample. Child Abus. Negl. 2019,98, 104233. [CrossRef] [PubMed]
Braun, T.D.; Quinn, D.M.; Stone, A.; Gorin, A.A.; Ferrand, J.; Puhl, R.M.; Sierra, J.; Tishler, D.; Papasavas, P. Weight Bias, Shame,
and Self-Compassion: Risk/Protective Mechanisms of Depression and Anxiety in Prebariatic Surgery Patients. Obesity
28, 1974–1983. [CrossRef]
Braun, T.D.; Gorin, A.A.; Puhl, R.M.; Stone, A.; Quinn, D.M.; Ferrand, J.; Abrantes, A.M.; Unick, J.; Tishler, D.; Papasavas, P.
Shame and Self-compassion as Risk and Protective Mechanisms of the Internalized Weight Bias and Emotional Eating Link in
Individuals Seeking Bariatric Surgery. Obes. Surg. 2021, 1–11. [CrossRef]
Fekete, E.M.; Herndier, R.E.; Sander, A.C. Self-Compassion, Internalized Weight Stigma, Psychological Well-Being, and Eating
Behaviors in Women. Mindfulness 2021,12, 1–10. [CrossRef]
Blum, A. Shame and guilt, misconceptions and controversies: A critical review of the literature. Traumatology
,14, 91–102.
Udo, T.; Grilo, C.M. Perceived weight discrimination, childhood maltreatment, and weight gain in U.S. adults with over-
weight/obesity. Obesity 2016,24, 1366–1372. [CrossRef] [PubMed]
Major, B.; Hunger, J.M.; Bunyan, D.P.; Miller, C.T. The ironic effects of weight stigma. J. Exp. Soc. Psychol.
,51, 74–80.
Atzl, V.M.; Narayan, A.J.; Rivera, L.M.; Lieberman, A.F. Adverse childhood experiences and prenatal mental health: Type of
ACEs and age of maltreatment onset. J. Fam. Psychol. 2019,33, 304–314. [CrossRef] [PubMed]
Feiring, C.; Taska, L.S. The Persistence of Shame Following Sexual Abuse: A Longitudinal Look at Risk and Recovery. Child Maltreatment
2005,10, 337–349. [CrossRef] [PubMed]
Dorahy, M.J.; Clearwater, K. Shame and Guilt in Men Exposed to Childhood Sexual Abuse: A Qualitative Investigation. J. Child
Sex. Abus. 2012,21, 155–175. [CrossRef] [PubMed]
Davis, J.L.; Petretic-Jackson, P.A. The impact of child sexual abuse on adult interpersonal functioning: A review and synthesis of
the empirical literature. Aggress. Violent Behav. 2000,5, 291–328. [CrossRef]
Thomson, P.; Jaque, S.V. Shame and Anxiety: The Mediating Role of Childhood Adversity in Dancers. J. Dance Med. Sci.
22, 100–108. [CrossRef] [PubMed]
Reid, J. The imprint of childhood abuse on trauma-related shame in adulthood. Dign. J. Sex. Exploit. Violence
,3. [CrossRef]
McLennan, J.D.; MacMillan, H.L.; Afifi, T.O. Questioning the use of adverse childhood experiences (ACEs) questionnaires.
Child Abus. Negl. 2020,101, 104331. [CrossRef]
Von Cheong, E.; Sinnott, C.; Dahly, D.; Kearney, P.M. Adverse childhood experiences (ACEs) and later-life depression: Perceived
social support as a potential protective factor. BMJ Open 2017,7, e013228. [CrossRef] [PubMed]
Pearl, R.L.; Puhl, R.M. Measuring internalized weight attitudes across body weight categories: Validation of the Modified Weight
Bias Internalization Scale. Body Image 2014,11, 89–92. [CrossRef] [PubMed]
Durso, L.E.; Latner, J.D. Understanding Self-directed Stigma: Development of the Weight Bias Internalization Scale. Obesity
16, S80–S86. [CrossRef]
Puhl, R.M.; Luedicke, J.; Heuer, C. Weight-Based Victimization Toward Overweight Adolescents: Observations and Reactions of
Peers. J. Sch. Health 2011,81, 696–703. [CrossRef]
Puhl, R.M.; Heuer, C.; Sarda, V. Framing messages about weight discrimination: Impact on public support for legislation.
Int. J. Obes. 2010,35, 863–872. [CrossRef] [PubMed]
Pearl, R.L.; Dovidio, J.F. Experiencing Weight Bias in an Unjust World: Impact on Exercise and Internalization. Health Psychol.
2015,34, 741–749. [CrossRef]
Racine, N.M.; Madigan, S.L.; Plamondon, A.R.; McDonald, S.W.; Tough, S.C. Differential Associations of Adverse Childhood
Experience on Maternal Health. Am. J. Prev. Med. 2018,54, 368–375. [CrossRef]
Pearl, R.L.; Wadden, T.A.; Hopkins, C.M.; Shaw, J.A.; Hayes, M.R.; Bakizada, Z.M.; Alfaris, N.; Chao, A.M.; Pinkasavage, E.;
Berkowitz, R.I.; et al. Association between weight bias internalization and metabolic syndrome among treatment-seeking
individuals with obesity. Obesity 2017,25, 317–322. [CrossRef]
... 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. ...
Conference Paper
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Weight-stigma and internalised weight-stigma are risks for EDs and suicidality. Suicidal ideation in current and lifetime EDs is directly and indirectly effected by perceived-burdensomeness. Similarly, research has linked weight-based discrimination with perceived-burdensomeness and increased suicidal ideation. Weight self-stigma has been linked with weight change, indicating the negative effects of weight self-stigma, and emphasising the central role of fear of being stigmatised by others in this process. Self-discrepancy and negative self-schemas may also include fear of an imagined fat/larger self, or fear of returning to a larger/fat body weight. Considering these factors in the relationship between weight stigma, fear of fatness, and disordered eating, it may be that fear-of-fatness and perceived burdensomeness in EDs more closely align with fear of weight-based discrimination. Pervasive, systemic devaluation of individuals in fat/larger bodies may foster internalised beliefs that one is worthless or a burden on society that praises thinness, dehumanises, pathologizes, and positions larger bodies as a moral/personal failure. This may compound minority stress and weight bias internalisation for those who face intersectional oppressions and experiences of their bodies and identities as a marginalised other. Fear of additional (weight-based) marginalisation may influence ED vulnerability for certain populations, including those who may experience intersectional marginalisation, and those in larger bodies. Insecure attachment, social anxiety, and fear of negative evaluation are also highly prevalent in EDs. It may be that these factors relate to increased awareness of the threat of weight-based marginalisation and therefore, heighten ED risk. This paper will explore the literature on ‘fear of fatness’, ‘feeling fat’, and negative ‘fat talk’ in EDs as related to internalised weight stigma, marginalisation (i.e., race/ethnicity, genders, sexualities, disability), perceived burdensomeness, and fear of stigmatisation. It will argue for the consideration of ‘fear of fatness’ and ‘feeling fat’ as central to ED within a broader context of body politics, weight-based discrimination and disordered eating as a means of coping with fear of (further) social discrimination.
Background: After bariatric surgery, some patients experience adverse psychiatric outcomes, including substance use, suicidality, and self-harm. These factors are commonly associated with posttraumatic stress disorder (PTSD) and related symptoms (PTSD-S) that develop following adverse childhood experiences (ACEs) and traumatic events. However, emerging evidence suggests that chronic discrimination also may contribute to PTSD-S. Weight-based discrimination is salient for people with obesity but has received little attention in relation to PTSD-S. Objective: Our study examined factors that may contribute to the link between experienced weight stigma (WS), which is common in individuals seeking bariatric surgery, and PTSD-S. Setting: Teaching hospital and surgical weight loss center in the United States. Methods: A total of 217 participants completed self-report surveys of experienced and internalized WS, ACEs, and PTSD-S. Demographics and trauma history were obtained from patient medical records. A stepwise multiple regression examined associations between experienced WS and internalized WS with PTSD-S, co-varying demographics, ACEs, and trauma, followed by examination of whether findings held co-varying anxiety/depressive symptoms in a participant subset (n = 189). Results: After accounting for covariates in step 1 and ACEs and trauma in step 2 (ΔR2 = .14), experienced WS and internalized WS accounted for substantial PTSD-S variance in steps 2 and 3 (ΔR2 = .12 and .13, respectively; overall model R2 =.44; P < .001). Findings held after co-varying anxiety/depressive symptoms. Conclusions: Over and above ACEs and trauma, experienced WS and internalized WS may contribute to PTSD-S. Longitudinal research is needed to better elucidate the pathways underlying these associations.
Purpose: This study investigated the relationship between internalized weight stigma (IWS) and visceral adipose tissue (VAT), an independent predictor of cardiometabolic disease risk, and how this relationship is moderated by gender. Methods: Participants (N=70, 81% white, 51% women, M age=30.4±7.8 years, M BMI=28.7±5.5 kg/m2, M BF%=32.4±8.9%) completed in-lab measures of demographic factors (age, gender, race/ethnicity), IWS (Weight Bias Internalization Scale-Modified; WBIS-M) and visceral adiposity. VAT mass was measured via DXA. Primary moderation analysis investigated the effect of gender on associations between IWS and VAT mass. Covariates were age, race/ethnicity, and total body fat percent. Results: After adjusting for covariates in the primary moderation analysis, WBIS-M scores displayed a positive association with VAT mass (b=32.58, p=0.033). The relationship between WBIS-M scores and VAT mass was moderated by gender (b=68.63, p=0.020); no relationship between WBIS-M scores and VAT mass was observed in men (b=-2.71, p=0.894), whereas a positive association between WBIS-M scores and VAT mass was observed in women (b=65.92, p=0.003). Conclusions: Internalization of weight stigma was associated with greater visceral adiposity in women across the BMI spectrum, suggesting it as a chronic stressor. Future studies should investigate directionality and causality of this relationship to elucidate mechanisms of stigma-associated CVD risk.
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Background Emotional eating in bariatric surgery patients is inconsistently linked with poor post-operative weight loss and eating behaviors, and much research to date is atheoretical. To examine theory-informed correlates of pre-operative emotional eating, the present cross-sectional analysis examined paths through which experienced weight bias and internalized weight bias (IWB) may associate with emotional eating among individuals seeking bariatric surgery. Methods We examined associations of experienced weight bias, IWB, shame, self-compassion, and emotional eating in patients from a surgical weight loss clinic (N = 229, 82.1% female, M. BMI: 48 ± 9). Participants completed a survey of validated self-report measures that were linked to BMI from the patient medical record. Multiple regression models tested associations between study constructs while PROCESS bootstrapping estimates tested the following hypothesized mediation model: IWB ➔ internalized shame ➔ self-compassion ➔ emotional eating. Primary analyses controlled for adverse childhood experiences (ACE), a common confound in weight bias research. Secondary analyses controlled for depressive/anxiety symptoms from the patient medical record (n = 196). Results After covariates and ACE, each construct accounted for significant unique variance in emotional eating. However, experienced weight bias was no longer significant and internalized shame marginal, after controlling for depressive/anxiety symptoms. In a mediation model, IWB was linked to greater emotional eating through heightened internalized shame and low self-compassion, including after controlling for depressive/anxiety symptoms. Conclusions Pre-bariatric surgery, IWB may signal risk of emotional eating, with potential implications for post-operative trajectories. Self-compassion may be a useful treatment target to reduce IWB, internalized shame, and related emotional eating in bariatric surgery patients. Further longitudinal research is needed.
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Objectives Research suggests that directing compassion inward (i.e., self-compassion) is related to better psychological and physical well-being. Little research attention has focused on the links between self-compassion and internalized weight stigma. Internalized weight stigma, or devaluing oneself because of one’s body weight, is pervasive across women regardless of their weight and is particularly detrimental to psychological and physical well-being.Methods This study examined the indirect effects of self-compassion on maladaptive eating behaviors through lower levels of internalized weight stigma and increased psychological well-being in a sample of 266 women. Women completed an online questionnaire assessing self-compassion, internalized weight stigma, anxiety and depressive symptoms, and emotional and restrained eating.ResultsSelf-compassion was associated with lower levels of internalized weight stigma, which in turn was associated with fewer depressive symptoms and less anxiety. Contrary to expectations, self-compassion was not associated with eating behaviors through the sequence of internalized weight stigma and psychological well-being. However, self-compassion was associated with less emotional and restrained eating through lower internalized weight stigma.Conclusions The link between self-compassion and fewer maladaptive eating behaviors was explained by internalized weight stigma alone, as opposed to a sequence of internalized weight stigma and psychological well-being.
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Objectives Burnout and occupational stress are frequently experienced by healthcare professionals (HCPs). Mindfulness-based stress reduction (MBSR) has been found to improve the psychological health outcomes of HCPs. To date, systematic reviews and meta-analyses have primarily focused upon empirical investigations into the reduction of stress amongst HCPs using MBSR and are limited to empirical studies published before December 2019. This systematic review aimed to update the current evidence base and broaden our understanding of the effectiveness of MBSR on improving the psychological functioning of HCPs. Methods Three electronic databases (Medline, Psych Info and Web of Science) were searched without time frame restrictions. Quantitative studies included randomised controlled trials, clinical controlled trials, pre-post designs and studies with up to a 12-month follow-up period. All studies included in the review employed a MBSR programme, standardised measures of psychological functioning and qualified HCPs as participants. Results Using PRISMA guidelines thirty studies were included in the review. The reviewed literature suggested that MBSR was effective in reducing HCPs experiences of anxiety, depression and stress. MBSR was also found to be effective in increasing HCP levels of mindfulness and self-compassion. However, MBSR did not appear as effective in reducing burnout or improving resilience amongst HCPs. Abbreviated MBSR programmes were found to be as effective as the traditional 8-week MBSR programmes. Conclusions MBSR is an effective intervention which can help improve the psychological functioning of HCPs. Recommendations include improving the overall quality of the studies by employing more robust controlled designs with randomisation, increased sample sizes with heterogeneous samples, and making active comparisons between interventions used.
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People with obesity commonly face a pervasive, resilient form of social stigma. They are often subject to discrimination in the workplace as well as in educational and healthcare settings. Research indicates that weight stigma can cause physical and psychological harm, and that affected individuals are less likely to receive adequate care. For these reasons, weight stigma damages health, undermines human and social rights, and is unacceptable in modern societies. To inform healthcare professionals, policymakers, and the public about this issue, a multidisciplinary group of international experts, including representatives of scientific organizations, reviewed available evidence on the causes and harms of weight stigma and, using a modified Delphi process, developed a joint consensus statement with recommendations to eliminate weight bias. Academic institutions, professional organizations, media, public-health authorities, and governments should encourage education about weight stigma to facilitate a new public narrative about obesity, coherent with modern scientific knowledge.
Objective Psychopathology in bariatric surgery patients may contribute to adverse postoperative sequelae, including weight regain, substance use, and self‐harm. This cross‐sectional study aimed to advance the understanding of the risk and protective paths through which weight bias associates with depressive and anxiety symptoms in bariatric surgery candidates (BSC). Methods BSC recruited from a surgical clinic (N = 213, 82.2% women, 43 [SD 12] years, mean BMI: 49 [SD 9] kg/m²) completed measures of experienced weight bias (EWB), internalized weight bias (IWB), body and internalized shame, and self‐compassion; anxiety and depression screeners were accessed from medical charts. Multiple regression and PROCESS bootstrapping estimates tested our hypothesized mediation model as follows: EWB→IWB→body shame→shame→self‐compassion→symptoms. Results After accounting for EWB and IWB, internalized shame accounted for greater variance in both end points than body shame. EWB was associated with greater anxiety through risk paths implicating IWB, body shame, and/or internalized shame. Protective paths associated EWB with fewer depressive and anxiety symptoms among those with higher self‐compassion. Conclusions The findings suggest a potentially important role for weight bias and shame in psychological health among BSC and implicate self‐compassion, a trainable affect‐regulation strategy, as a protective factor that may confer some resiliency. Future research using longitudinal and causal designs is warranted.
Adverse childhood experiences (ACEs) are increasingly recognized as important predictors of poor health outcomes. In response, there is increasing application of ACEs questionnaires in clinical practice and population health surveys. Such efforts are often justified as approaches to identify ACEs, components of trauma-informed care, and/or measures to determine prevalence within epidemiological research. Unfortunately, such measures are often used without evaluating the strengths and limitations of the measures themselves. One of the most commonly used ACEs questionnaires is a ten-question version (ACEs-10), that is composed of two clusters - one asking about different types of child maltreatment, and the other asking select questions about household challenges. Unfortunately, both this questionnaire and its derivatives have substantial drawbacks that warrant careful consideration about their use. Problems include limited item coverage, collapsing of items and response options, a simplistic scoring approach, and the lack of psychometric assessment. These deficiencies are inconsistent with the standards expected for use of measures in healthcare services and research. Given these deficiencies, we recommend that these limitations are addressed before further use of ACEs-10, and its derivatives, for either clinical or research purposes.
Background: Adverse childhood experiences (ACEs) have been linked with an increased tendency to experience self-conscious emotions (i.e., shame- and guilt-proneness). Further, interpersonal problems have been associated with ACEs and are implicated in the maintenance of shame and guilt-proneness. Objective: The aim of the present study was to better understand the interpersonal pathways through which ACEs are associated with shame- and guilt-proneness. Method: A community sample (N=249) completed measures of ACEs, interpersonal problems, and shame- and guilt-proneness. Results: Interpersonal problems mediated the association between ACEs and shame-proneness and ACEs and guilt-proneness. Multiple mediation models revealed that—when controlling for the other types of interpersonal problems—(a) interpersonal sensitivity was the only significant mediator between ACEs and shame-proneness and (b) interpersonal sensitivity and interpersonal aggression mediated the association between ACEs and guilt-proneness. Conclusions: These findings highlight the importance of interpersonal pathways in the association between shame- and guilt-proneness. Theoretical and practical implications are discussed.
Background: The relationship of health risk behavior and disease in adulthood to the breadth of exposure to childhood emotional, physical, or sexual abuse, and household dysfunction during childhood has not previously been described. Methods: A questionnaire about adverse childhood experiences was mailed to 13,494 adults who had completed a standardized medical evaluation at a large HMO; 9,508 (70.5%) responded. Seven categories of adverse childhood experiences were studied: psychological, physical, or sexual abuse; violence against mother; or living with household members who were substance abusers, mentally ill or suicidal, or ever imprisoned. The number of categories of these adverse childhood experiences was then compared to measures of adult risk behavior, health status, and disease. Logistic regression was used to adjust for effects of demographic factors on the association between the cumulative number of categories of childhood exposures (range: 0-7) and risk factors for the leading causes of death in adult life. Results: More than half of respondents reported at least one, and one-fourth reported ≥2 categories of childhood exposures. We found a graded relationship between the number of categories of childhood exposure and each of the adult health risk behaviors and diseases that were studied (P < .001). Persons who had experienced four or more categories of childhood exposure, compared to those who had experienced none, had 4- to 12-fold increased health risks for alcoholism, drug abuse, depression, and suicide attempt; a 2- to 4-fold increase in smoking, poor self-rated health, ≥50 sexual intercourse partners, and sexually transmitted disease; and a 1.4- to 1.6-fold increase in physical inactivity and severe obesity. The number of categories of adverse childhood exposures showed a graded relationship to the presence of adult diseases including ischemic heart disease, cancer, chronic lung disease, skeletal fractures, and liver disease. The seven categories of adverse childhood experiences were strongly interrelated and persons with multiple categories of childhood exposure were likely to have multiple health risk factors later in life. Conclusions: We found a strong graded relationship between the breadth of exposure to abuse or household dysfunction during childhood and multiple risk factors for several of the leading causes of death in adults.
Background: Acquiring more complex coping strategies despite a history of childhood adversity may transpire in settings outside the family home. Objectives: The objectives of this cross-sectional study included investigating coping strategies under stressful situations in a non-clinical sample of active athletes and performing artists. Participants and setting: In this community and university sample (n = 577), 40.4% had no ACEs, 43.4% had 1-3 ACEs, and 16.3% had ≥4 ACEs. Methods: A series of multivariate analyses (gender and age included as covariates) were conducted to examine differences between the three ACE groups. Results: Results indicated no between-subject differences between the three ACE groups for flow-like experiences during preferred activities, although gender differences were significant (p < .001). Individuals in the ≥4 ACEs group endorsed more intense creative experiences compared to the no-ACE and 1-3 ACEs groups (p = .006, η2 = .048); however, in the third MANCOVA they had heightened anxiety, internalized shame, dissociative processing, emotion-oriented coping, and cumulative trauma (p < .001, η2 = .132). There were no group differences for task-oriented and avoidant-oriented coping, a finding that highlights the ability of active individuals to engage in effective coping strategies under stressful situations. Conclusion: Regardless of past childhood adversity history, this non-clinical high achieving sample was able to engage in a range of coping strategies under stress.
Childhood adversity can have long-term deleterious effects on adulthood mental health outcomes, but more research is needed examining how type and timing of childhood adversity affect mental health specifically during pregnancy. The current study examined the effects of total adverse childhood experiences (ACEs) on depression and posttraumatic stress disorder (PTSD) symptoms during pregnancy, unpacked effects of total adversity into childhood maltreatment versus family dysfunction experiences, and assessed age of onset effects of child maltreatment-specific experiences. Participants were 101 low-income pregnant women (M = 29.10 years, SD = 6.56, range = 18-44; 37% Latina, 22% African American, 20% White, 13% biracial/multiracial, 8% other; 26% Spanish-speaking) who completed instruments on childhood adversity, PTSD and depression symptoms during pregnancy, and demographics. Results indicated that total ACEs predicted elevated PTSD and depression symptoms during pregnancy, as did maltreatment ACEs, but not family dysfunction ACEs. Early childhood onset of maltreatment significantly predicted elevated PTSD symptoms during pregnancy, whereas middle childhood and adolescent onset did not. No age of onset of maltreatment variable significantly predicted depression symptoms during pregnancy. Findings underscore the importance of differentiating between childhood maltreatment versus family dysfunction ACEs and examining the timing and accumulation of maltreatment experiences during childhood, because these factors affect mental health during pregnancy. Findings also support universal prenatal screening for PTSD symptoms to identify at-risk pregnant women who could benefit from interventions to disrupt the intergenerational transmission of risk and give families the healthiest possible beginning. (PsycINFO Database Record (c) 2019 APA, all rights reserved).