Literature Review

Weight Stigma

Weight stigma is the social rejection, judgement, or devaluation of an individual on the basis of their weight (Blodorn, Major, Hunger, & Carol, 2016). Historically western beauty standards have perceived thin women positively and perceived heavy women negatively (Blodorn et al, 2016), perpetuating stereotypes of the overweight population (O’Brien et al, 2016). Currently overweight and obese individuals comprise the majority of the American adult population, but are increasingly affected by weight stigma (Schafer & Ferraro, 2011). Perceived weight stigma threatens an effected individual’s feeling of security within a society and leads to social rejection (Blodorn et al, 2016).

Social rejection.

Bodily differences can lead to social rejection, altering the perception of one’s self-identity (Goffman, 1963). Self-preservation theory states judgement and devaluation is internalized as a threat to life (Himmelstein et. al, 2015). Perceived threats produce bodily arousal to face the dangerous situation and subsequent feelings of shame (Rohleder, Chen, Wolf, & Miller, 2008).  Research indicates that bodily arousal leads to worsened health outcomes overtime (Rohleder et al, 2008) and consequently increases risk for physical and psychological impacts (Blodorn et al, 2016).

Impacts of Weight Stigma

Stigmatizing individuals on the basis of their weight can produce negative psychological and physiological effects (Himmelstein, Puhl, & Quinn, 2018). Psychological impacts include increased self-consciousness, weakened self-esteem (Blodorn et al, 2016), increased body dissatisfaction, and increased psychological stress (O’Brien et al, 2016). The psychological stress produced may alter typical physiological responses, leading to further functional disturbances (Blodorn et al, 2016).

Psychological disorders.

Women facing discrimination are at risk for developing psychiatric disorders (Blodorn et al, 2016). Depressive disorders may develop (Hunger & Major, 2014) involving a low mood, cognitive distortions, emptiness or irritability that interferes with daily functioning (American Psychiatric Association APA, 2013). Anxiety disorders may occur (Hunger & Major, 2014), producing disturbances in thought and behavior (APA, 2013). Anxiety disorders stem from insistent worry, causing arousal of the autonomous nervous system (APA, 2013). Bodily symptoms of restlessness, lethargy, and muscle tension may result (APA, 2013). Stigmatized individuals may avoid anxiety-inducing situations to avoid symptoms leading to an interference with daily activities (Drury & Louis, 2002). Stigma can lead to eating disturbances and eating disorders (Himmelstein, Puhl, & Quinn, 2018). Eating disorders are disturbances in eating behaviors that impair cognitive and physiological processes (APA, 2013). Binge-eating disorder, a disorder marked by uncontrolled eating, is often associated with overweight and obese individuals (APA, 2013).  The diagnostic criteria for binge-eating disorder is independent of weight, and is not present in all overweight individuals (APA, 2013). Mental health issues are a separate form of stigmatization from weight stigma, which can further negative effects on self-perception, ability, and place in society (Sickel, Seacat, & Nabors, 2014). Research indicates healthy lifestyle behaviors combined with positive affect protect against the impacts of weight stigma (Himmelstein et al, 2018). Mental health plays an important mediating role in managing physical effects in the weight-stigmatized population (Himmelstein et al, 2018).

Stress.

Weight stigma induced emotional stress can increase oxidative stress levels in the body (Blodorn et al, 2016). Oxidative stress is an imbalance between antioxidants and oxygen in the body leading to chronic conditions such as cancer, diabetes, cardiovascular diseases, and inflammatory diseases (Prieser, 2012). Additional repercussions include increased blood pressure, increased cortisol levels, and weakened executive function (Blodorn et al, 2016). Executive functions are responsibilities of the frontal lobe involving processes of cognition and memory (Blair, 2017).

Cortisol.


Cortisol is a hormone secreted in times of stress (Soravia & F. de Quervain, 2012). It is secreted by the adrenal gland located in the frontal lobe (Blair, 2017). Cortisol’s inverse relationship with executive function may explain confusion regarding memories of stressful events (Soravia & F. de Quervain, 2012). Individuals who face weight discrimination may misremember the incident, magnifying a negative perception of a potentially neutral situation (Soravia & F. de Quervain, 2012). Research indicates cortisol secretion levels and self-perception of stigma are positively correlated (Himmelstein, Incollingo Belsky, & Tomiyama, 2015). The positive correlation results from previously defined self-preservation theory (Himmelstein et. al, 2015). The increase in perception of weight stigma causes a subsequent increase in cortisol levels, which may increase appetite and caloric intake (Himmelstein et al., 2015). The relationship between overeating and weight stigmatization may elevate the risk of obesity (Blodorn et. al, 2016). Cortisol influences fat-deposit storage, leading excess fat to be stored in the abdomen (Himmelstein et. al, 2015).

Metabolic syndrome.


Excess abdominal fat from cortisol secretion puts an individual at risk for developing metabolic syndrome (Constantinopoulos et. al, 2015). Metabolic syndrome is a group of conditions that may lead to debilitating ailments including heart disease and cancer (Reaven, 1988). Insulin resistance, increased inflammatory responses, increased blood pressure, and increased blood sugar resulting from metabolic syndrome may further perpetuate weight gain (Wasko, 2015). Abdominal fat associated with metabolic syndrome is not easy to lose due to underlying physiological changes (Wasko, 2015). Decreased motivation towards (Hunger & Major, 2014) and avoidance of (Himmelstein et. al, 2018) physical activity in the overweight population may further lead to the maintenance of cortisol-induced abdominal weight. Metabolic syndrome is dangerous and must be addressed promptly by the healthcare system (Wasko, 2015).

Weight Stigma in Healthcare

Overweight individuals may be less likely to seek psychological or physical treatment for their health concerns due to perceived weight stigma in the healthcare industry (Himmelstein et. al., 2015). Research indicates among overweight women there is a positive relationship between body mass index and delaying healthcare treatment (Drury & Louis, 2002). Healthcare professional’s inaccurate perceptions of the overweight population lead to further stigmatization (Drury & Louis, 2002) demonstrating a critical need for sensitive and informed care (Puhl & Suh, 2015).

Bias.

Healthcare professionals’ express attitudes of frustration and bias towards overweight individuals (Phelan et al, 2015). Research indicates professionals demonstrating high levels of weight bias assign high levels of negative characteristics to their overweight patients (Phelan et al, 2015). Healthcare professionals have a negative perception of overweight patients (Drury & Louis, 2002) attributing lack of will-power (Wear, Aultman, Varley, & Zarconi, 2006) and gluttony (Puhl & Suh) to their condition. Obesity is viewed professionally as avoidable, leading to feelings of discrimination and annoyance among healthcare professionals (Phelan et al, 2015). Patient’s may be discussed among professional colleagues in a derogatory or cynical manner (Wear et al, 2006). Negative discussions about the overweight population may strengthen stigma and lessen the patient’s trust in the healthcare system (Wear et al, 2006).

Communication.

Healthcare professional’s implicit and explicit bias negatively impact patient-doctor communication (Phelan et al, 2015). Verbal and physical communication exhibited by both the patient and healthcare professional effect perceptions of each other (Street Jr., Gordon, & Haidet, 2007). Research indicates healthcare providers favor patients who have strong communication skills (Street Jr. et al, 2007). Communication skills in stigmatized populations may be weakened in a healthcare setting due to stigma anxieties (Persky & Eccleston, 2011). Utilizing fat-phobic and stigmatizing language should be avoided for respect and quality care (Puhl & Suh, 2015). Research suggests healthcare providers utilizing sensitive language and communication make a positive impact on stigmatized patients’ treatment-seeking behavior (Puhl & Suh, 2015).

Misunderstanding.

Biased professionals may minimize patient health problems by attributing most concerns to their weight (Phelan et al, 2015). Unsolicited and oversimplified weight loss advice may further invalidate the patient’s concerns (Phelan et al, 2015). Research indicates that overweight individuals are more likely to be prescribed lifestyle changes over medication compared to typical-weight patients (Persky & Eccleston, 2011). Excess abdominal fat in the overweight population is persistent (Wasko, 2015) and difficult to lose by doctor’s standard recommendations of diet and exercise (Hall et al, 2012). Inaccurate and unwanted advice may lead to mutual frustration and miscommunication among patient and healthcare professionals (Street Jr. et al, 2007). Perceived stigma may lead to health care avoidance eliminating preventative care and worsening preexisting health conditions (Phelan et al, 2015).

Current Study

A study seeking to improve healthcare professionals understanding of the overweight patients has yet to be evaluated in the literature. Research suggests that stigma may be perceived even in the absence of explicit discrimination (Phelan et al, 2015) demonstrating the critical need for awareness of healthcare professional’s weight biases. Diet and exercise are commonly prescribed to the overweight population (Hall et al, 2012) demonstrating a lack of empirical understanding of the population’s weight and subsequent physical challenges (Wasko, 2015). The proposed study seeks to evaluate the role of bias in healthcare treatment of the overweight population.

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