Sexual Minority Women Report Higher Weight Stigma Levels Than Heterosexual Women in the National Weight Control Registry.

BACKGROUND: Little is known about weight stigma in sexual minority women, and even less is known about weight stigma in those who have attained substantial weight loss and maintenance. PURPOSE: This study examined weight stigma experiences and internalization in sexual minority women from the National Weight Control Registry (NWCR) who had lost ≥30 pounds and maintained this weight loss for ≥1 year, and compared weight stigma levels between sexual minority women versus heterosexual women in the NWCR. METHODS: NWCR participants completed an electronic survey. Women who identified as a sexual minority (n = 64; 98% White; MBMI = 29 ± 8; Mage = 47 ± 13) and heterosexual women matched on body mass index (BMI), age, and race (n = 64; 98% White; MBMI = 28 ± 7; Mage = 51 ± 13) were included. Participants completed assessments of experienced and internalized weight stigma. RESULTS: Generalized linear models showed that a significantly larger proportion of sexual minority women in the NWCR reported experiencing weight stigma in the past year (24.2%) compared with heterosexual women (4.7%; p < .05). Furthermore, sexual minority (vs. heterosexual) women reported significantly higher levels of internalized weight stigma (p < .001), and a greater proportion of sexual minority women (35%) reported clinically significant internalized weight stigma relative to heterosexual women (2%; p < .001). CONCLUSIONS: Sexual minority women are at greater risk for experienced and internalized weight stigma than their heterosexual counterparts among women who have attained significant long-term weight loss. It is critical to expand research on weight stigma in sexual minority women.

This study examined weight stigma experiences and internalization in sexual minority women who attained substantial weight loss and maintenance, compared with heterosexual women of similar body mass index (BMI), race, and age, in a sample of adults from the National Weight Control Registry. Results showed that 24% of sexual minority women reported experiencing weight stigma in the past year and 35% reported clinically meaningful internalized weight stigma, levels that were higher than those of heterosexual women of similar BMI, age, and race in the sample. These data suggest that sexual minority women who have attained major weight loss may be at greater risk for weight stigma than heterosexual women with similar weight losses.

Pragmatic Implementation of Online Obesity Treatment and Maintenance Interventions in Primary Care: A Randomized Clinical Trial.

Importance: Behavioral weight loss interventions have achieved success in primary care; however, to our knowledge, pragmatic implementation of a fully automated treatment that requires little researcher oversight has not been tested. Moreover, weight loss maintenance remains a challenge. Objective: To evaluate the long-term effectiveness of an automated, online, behavioral obesity treatment program (Rx Weight Loss [RxWL]) at 12 months (primary end point) and 24 months when delivered pragmatically in primary care and to compare the effectiveness of 3 weight loss maintenance approaches. Design, Setting, and Participants: This randomized clinical trial of RxWL, an online weight loss program, recruited patients from a Rhode Island primary care network with approximately 60 practices and 100 physicians. Eligible participants were primary care patients aged 18 to 75 years with overweight or obesity who were referred by their nurse care manager and enrolled between 2018 and 2020. All participants were included in the intention-to-treat analysis, whereas only those who engaged with maintenance intervention were included in the per-protocol analysis. Data were analyzed from August 2022 to September 2023. Interventions: All participants were offered the same 3-month weight loss program, with randomization to one of three 9-month maintenance programs: control intervention (monthly online newsletters), monthly intervention (9 monthly video lessons and 1 week of self-monitoring per month), or refresher intervention (an introductory session and two 4-week periods of lessons and self-monitoring at 7 and 10 months). Main Outcomes and Measures: The primary outcome was weight change at 12 months using height and weight data collected from electronic medical records through 24 months. Results: Among the 540 participants (mean [SD] age, 52.8 [13.4] years; 384 females [71.1%]) in the intention-to-treat analysis, mean estimated 3-month weight loss was 3.60 (95% CI, -4.32 to -2.88) kg. At the 12-month primary end point, the amount of weight regained in the monthly (0.37 [95% CI, -0.06 to 0.81] kg) and refresher (0.45 [95% CI, 0.27 to 0.87] kg) maintenance groups was significantly less than that in the newsletter control maintenance group (1.28 [95% CI, 0.85 to 1.71] kg; P = .004). The difference in weight regain between the monthly and refresher maintenance groups was not statistically significant. This pattern persisted at 24 months. In the per-protocol analysis of 253 participants, mean weight loss at the end of the initial 3-month intervention was 6.19 (95% CI, -7.25 to -5.13) kg. Similarly, at 12 months there was less weight regain in the monthly (0.61 kg) and refresher (0.96 kg) maintenance groups than in the newsletter control maintenance group (1.86 kg). Conclusions and Relevance: Results of this randomized clinical trial indicate that pragmatic implementation of a 12-month automated, online, behavioral obesity treatment that includes 9 months of active maintenance produces clinically significant weight loss over 2 years in primary care patients with overweight or obesity. These findings underscore the importance of providing ongoing maintenance intervention to prevent weight regain. Trial Registration: ClinicalTrials.gov Identifier: NCT03488212.

Changes in body weight and glycemic control in association with COVID-19 Shutdown among 23,000 adults with type 2 diabetes.

AIMS: To examine the association between COVID-19 Shutdown and within-subjects changes in body weight, body mass index (BMI), and glycemic parameters using electronic health record (EHR) data from 23,000 adults with type 2 diabetes (T2DM). METHODS: Patients with T2DM with outpatient visit data on body weight, BMI, hemoglobin A1c (HbA1c), and blood glucose (≥ 2 measures before and after 3/16/2020) recorded in the EHR at the University of Pittsburgh Medical Center were included. A within-subjects analysis compared average and clinically significant changes in weight, BMI, HbA1c, and blood glucose during the year POST-Shutdown (Time 2-3) compared to the same interval during the PRE-Shutdown year (Time 0-1) using paired samples t-tests and the McNemar-Bowker test. RESULTS: We studied 23,697 adults with T2DM (51% female; 89% White; mean age = 66 ± 13 years; mean BMI = 34 ± 7 kg/m2; mean HbA1c = 7 ± 2% [53 ± 21.9 mmol/mol]). Weight and BMI decreased during both the PRE- and POST-Shutdown intervals, but the changes were statistically smaller during the year POST-Shutdown relative to PRE (0.32 kg and 0.11 units, p < 0.0001). HbA1c showed statistically greater improvements during the POST-Shutdown interval compared to PRE (- 0.18% [-2 mmol/mol], p < 0.0001), but changes in glucose did not differ for the two intervals. CONCLUSIONS: Despite widespread discussion of weight gain in association with the COVID-19 Shutdown, study data showed no evidence of adverse effects of Shutdown on body weight, BMI, HbA1C, or blood glucose in a large sample of adults with T2DM. This information may help to inform future public health decision-making.

Association of Weight-Related Stigmas With Daily Pain Symptoms Among Individuals With Obesity.

BACKGROUND: Individuals with obesity are disproportionately impacted by pain-related symptoms. PURPOSE: This study evaluated experienced weight stigma and internalized weight bias (IWB) as predictors of pain symptoms in daily life among individuals with obesity. METHODS: Adults with obesity (n = 39; 51% female, 67% White, 43.8 ± 11.6 years old, BMI = 36.8 ± 6.7 kg/m2) completed a baseline assessment (demographics, experienced weight stigma, IWB) and a 14-day Ecological Momentary Assessment (EMA) period involving five daily prompts of pain/aches/joint pain, muscle soreness, experienced weight stigma, and IWB. Generalized linear models were used to assess experienced weight stigma and IWB at baseline as prospective predictors of EMA pain/soreness symptoms. Multi-level models were used to test the association of momentary weight stigma experiences and IWB with pain/soreness at the same and subsequent EMA prompts. RESULTS: IWB at baseline, but not experienced weight stigma, was associated with more frequent pain symptoms (p < .05) and muscle soreness (p < .01) during EMA. Momentary IWB (but not experienced stigma) was associated with more pain/aches/joint pain and muscle soreness at the same and subsequent prompt. CONCLUSIONS: Internalized (but not experienced) weight bias was prospectively associated with pain symptoms in daily life among individuals with obesity. Results are consistent with growing evidence that weight-related stigmas represent psychosocial factors that contribute to weight-related morbidity typically attributed to body size.

Examining the role of experiential avoidance and valued action in the negative effects of weight self-stigma.

Harmful effects of weight self-stigma on quality of life and health behaviors have been well-established. However, the processes that lead to these negative outcomes are less understood. Psychological inflexibility is defined as a pattern of rigid psychological reactions dominating over values and meaningful actions. A lack in valued action is characterized by the absence of activities that are connected to what is personally meaningful. In this secondary analysis, we aim to extend research by examining two subprocesses of psychological inflexibility, experiential avoidance and lack of valued action, as statistical mediators of the relations between weight self-stigma and quality of life/health behavior outcomes. Baseline data from a clinical trial comparing weight loss maintenance interventions in a sample of 194 adults living with overweight or obesity and seeking treatment is analyzed. Results show that greater experiential avoidance and lower valued action were significantly related to lower quality of life and satisfaction with social roles, as well as greater depression, anxiety, and binge eating. Further, results from a parallel mediation analysis indicated that weight self-stigma is indirectly related to anxiety, disinhibited eating, and hunger through the relationship with experiential avoidance and lack of valued action.

Internalized weight stigma in women with class III obesity: A randomized controlled trial of a virtual lifestyle modification intervention followed by a mindful self-compassion intervention.

Background: Internalized weight stigma (Internalized-WS) is prevalent among individuals with severe obesity, particularly women, and is associated with shame, disordered eating, and weight gain. Effective, accessible interventions that address both severe (Class-III) obesity and Internalized-WS are needed. This randomized pilot trial evaluated the feasibility, acceptability, and preliminary efficacy of a fully-remote lifestyle modification intervention (LM) followed by mindful self-compassion training (MSC) or control. Methods: Twenty-eight women with Class-III obesity (46.6 ± 3.7 kg/m2) and elevated Internalized-WS were randomized to a virtually-delivered 4-month LM followed by a 2-month MSC or cooking/dietary education (CON). Psychosocial measures/weight were assessed at baseline, 4-(post-LM), 6-(post-MSC/CON), and 9-month (follow-up). Results: Improvements in Internalized-WS, shame, and self-compassion were observed with LM. Mean 4-month weight loss was 6.3 ± 3.7%. MSC had lower attendance and usefulness ratings versus CON. Post-MSC/CON, MSC yielded significant and/or meaningful improvements in Internalized-WS, self-compassion, and intuitive eating relative to CON. Weight loss did not differ by group at 6-month, and at 9-month trended lower in MSC versus CON. Conclusion: Virtual LM is feasible, acceptable, and leads to significant weight loss among women with severe obesity; MSC led to further improved Internalized-WS, self-compassion, and intuitive eating. Continued work is needed to elucidate effects of self-compassion training on Internalized-WS, its mechanisms, and linkages to cardiometabolic health and long-term weight loss.

Pragmatic implementation of a fully automated online obesity treatment in primary care.

OBJECTIVE: Behavioral obesity treatment implemented in primary care is efficacious but typically involves face-to-face or phone contact. This study evaluated enrollment, engagement, and 12-week weight loss in a fully automated online behavioral weight-loss intervention implemented pragmatically in a primary care network. METHODS: As part of routine primary care, providers and nurse care managers offered a no-cost online obesity treatment program to 1,721 patients. Of these, 721 consented and were eligible (aged 18-75 years with BMI ≥ 25 kg/m2 and internet access), and 464 started the program. The program included 12 weekly online lessons, a self-monitoring platform, and automated feedback. RESULTS: More than one-quarter of patients who were offered the program (26%) initiated treatment. In intent-to-treat analyses using all data available, mean 12-week weight change was -5.10% (SE = 0.21). Patients who submitted their weights on all 12 weeks (37% of 464) lost an estimated 7.2% body weight versus 3.4% in those submitting less frequently. CONCLUSIONS: This fully automated online program, implemented into the routine workflow of a primary care setting without any human counseling or researcher involvement, produced clinically meaningful short-term weight loss. Greater program engagement was associated with greater weight loss; efforts are needed to understand barriers to engagement.

Affective responses to overeating episodes in women participating in a behavioral weight loss program.

BACKGROUND: Much research has focused on precursors to dietary lapses in weight loss programs, but less is known about how individual responses to lapses may influence future non-adherence and program success. The current study examined affective responses to overeating lapses and their influence on subsequent overeating and overall weight loss. METHODS: Women (n = 60) with overweight or obesity (BMI (mean ± SD): 34.3 ± 3.9 kg/m2; age: 48.1 ± 10.1 years) participated in a 3-month group behavioral weight loss intervention (BWLI). At baseline and 3 months, participants completed anthropometric assessments and a 10-day ecological momentary assessment protocol sent 5 times per day reporting on overeating and affect (stress, shame, anxiety, and feeling good about oneself). Across time points, multilevel models were used to examine affective responses to overeating and to predict likelihood of subsequent overeating. Linear regression models were used to examine the effect of affective responses to overeating (at baseline and collapsed across time points) on weight loss. RESULTS: Following self-reported overeating episodes, compared to non-overeating episodes, feeling good about oneself decreased. These decreases lessened with time from overeating. Overeating predicted subsequent overeating episodes, with decreases in feeling good about oneself following overeating marginally predicting increased likelihood (p = 0.065). Neither overeating frequency at baseline nor change in overeating frequency predicted weight loss; however, greater decreases in anxiety following overeating were associated with less weight loss. CONCLUSIONS: Self-reported overeating during a BWLI was associated with negative affective responses and may have increased the likelihood of subsequent overeating, but did not affect overall weight loss in this sample.

HIV Status, Obesity, and Risk for Weight Stigma: Comparing Weight Stigma Experiences and Internalization Among Adults with Obesity with and Without HIV.

Little is known about weight stigma among people living with HIV (PLWH). This study examined whether levels of perceived weight stigma experiences and internalization, assessed retrospectively and naturalistically, differed among adults with obesity based on HIV status. 50 PLWH (BMI = 35 kg/m2) and 51 adults without HIV (BMI = 36 kg/m2) completed retrospective assessments of lifetime perceived weight stigma experiences/internalization. Next, participants were invited to complete an optional 2-week Ecological Momentary Assessment study. 28 PLWH and 39 adults without HIV completed five momentary assessments of perceived weight stigma experiences/internalization daily. In covariate-adjusted models, PLWH reported 1.2-2.8 times lower frequency of lifetime and momentary perceived weight stigma experiences than adults without HIV, but levels of retrospectively- and naturalistically-assessed internalized weight stigma did not differ between groups. Findings suggest that HIV status may buffer against perceptions of weight stigma events, but not internalized weight stigma, highlighting weight stigma as an important area for future research in PLWH.

Multiply marginalized: Linking minority stress due to sexual orientation, gender, and weight to dysregulated eating among sexual minority women of higher body weight.

OBJECTIVE: This study assessed whether baseline levels of distal and proximal minority stressors related to sexual orientation, gender, and weight were associated with prospective risk for dysregulated eating in daily life among sexual minority women with overweight/obesity. METHODS: Fifty-five sexual minority women ages 18-60 (M = 25 ± 9) with BMI > 25kg/m2 (M = 32 ± 5) completed baseline assessments of distal and proximal minority stressors due to sexual orientation, gender, and weight. Participants then completed an Ecological Momentary Assessment (EMA) protocol. For five days, participants responded to five random prompts assessing engagement in dysregulated eating (i.e., overeating, binge eating). The cumulative number of EMA-measured overeating and binge eating episodes was summed per participant. RESULTS: Several minority stressors related to sexual orientation, gender, and weight were associated with prospective risk for dysregulated eating behaviors during EMA. Women with higher (vs. lower) baseline levels of internalized homophobia reported more cumulative episodes of binge eating during the EMA period. Women reporting greater (vs. less) baseline sexual orientation concealment reported more episodes of overeating during the EMA period. Women with greater (vs. less) baseline weight bias experiences and internalization reported more overeating and binge eating episodes during the EMA period. CONCLUSIONS: Findings from this pilot study identify internalized homophobia, sexual orientation concealment, and experienced and internalized weight bias as potential risk factors for dysregulated eating behaviors among sexual minority women of higher body weight.

State versus trait weight, shape, and eating concerns: Disentangling influence on eating behaviors among sexual minority women.

This study examined the relative influence of trait and state weight, shape, and eating concerns on dysregulated eating in the daily lives of sexual minority women with overweight and obesity. This study is a secondary analysis of data from an Ecological Momentary Assessment (EMA) study of 55 sexual minority women with overweight/obesity. Trait shape, weight, and eating concerns were assessed at baseline. For the following five days, participants used a smartphone to report state weight/shape concerns, overeating, and binge eating five times daily. Women who endorsed higher levels of trait weight, shape, and eating concerns at baseline reported more frequent state weight/shape concerns in daily life. Trait eating concerns were associated with higher odds of binge eating during EMA, but trait weight/shape concerns were unrelated to future dysregulated eating. In daily life, state weight/shape concerns was associated with greater risk for over/binge eating at the concurrent EMA prompt, the subsequent EMA prompt, and over the course of a full day, independent of trait concerns. State weight and shape concerns may play an important role in predicting dysregulated eating in daily life among sexual minority women of higher body weight.

Body shape concerns across racial and ethnic groups among adults in the United States: More similarities than differences.

This study evaluated the relationship between race/ethnicity and body shape concerns among adults in the U.S. and evaluated if this relationship varied by Body Mass Index (BMI) and gender. Data were collected from U.S. adults (N = 2,212) using a national online survey panel designed to approximate the US census data. Gender, age, race/ethnicity, BMI and body shape concerns (Body Shape Questionnaire) were assessed. Analysis of variance was utilized to evaluate the race/ethnicity and BSQ association and if the relationship varied by gender and BMI category. The sample (65 % White, 13 % Black/African American, 16 % Latino/Hispanic/Mexican American and 6 % Asian/Pacific Islander) was 50 % female; mean age of 44.2 years (SD = 16.8); BMI of 27.4 (SD = 6.7). A gender by BMI category interaction (p < .01) revealed no difference in BSQ scores by gender when BMI < 18, but higher BSQ scores among women for all other BMI groups. A main effect of race/ethnicity revealed BSQ scores were equally high across racial/ethnic groups, except individuals who identified as White (M = 42.0, SD = 19.7) reported higher BSQ than those identified as Asian/Pacific Islander (M = 37.4, SD = 17.4). Body shape concerns are common among US adults. Individuals of racial/ethnic minority status may experience similar gender- and BMI-related differences in body shape concerns as White individuals.

Characterizing Lifetime and Daily Experiences of Weight Stigma among Sexual Minority Women with Overweight and Obesity: A Descriptive Study.

Sexual minority women are disproportionately impacted by obesity yet are underrepresented in weight stigma research. This Ecological Momentary Assessment (EMA) study is a secondary analysis that aimed to elucidate the frequency and contextual characteristics of perceived experiences of lifetime and momentary weight stigma among sexual minority women with overweight/obesity. Participants were 55 sexual minority women ages 18-60 with a body mass index ≥25 kg/m2. Perceived lifetime weight stigma events were assessed at baseline. For the subsequent five days, participants used a smartphone to complete five daily, random EMA prompts assessing the frequency/characteristics of perceived weight stigma events in daily life. All participants reported at least one lifetime weight stigma event. During the EMA period, participants reported 44 momentary weight stigma events (M = 0.80), with 24% of participants reporting at least one event. During most instances of weight stigma, women perceived the stigma's cause to be their weight and another minority identity (e.g., sexual orientation). Findings showing high rates of perceived lifetime weight stigma in this sample and frequent co-occurrence of perceived weight stigma with stigma due to other marginalized identities in daily life underscore the need for future, larger studies investigating weight stigma through an intersectional lens in sexual minority women with overweight/obesity.

Behavioral Weight Loss: A Promising Treatment for Obesity in Adults with HIV.

Obesity and chronic disease are growing problems among people living with HIV (PLWH) across the globe. While a variety of treatments have been developed to address cardiovascular and metabolic disease among PLWH, few treatments have focused on helping PLWH and obesity lose weight. In the general population, behavioral weight loss interventions (i.e., diet, physical activity, and behavior therapy) are the first-line treatment for adults for whom weight loss is recommended. However, little research has tested whether the benefits of these programs translate to PLWH. This paper highlights the key components of behavioral weight loss programs, their outcomes in the general population and in the few studies of PLWH, and suggestions for tailoring these programs for PLWH. Behavioral weight loss programs are a strong potential treatment for reducing the burden of obesity among PLWH and merit future research attention.

Feasibility of Pairing Behavioral Activation With Exercise for Women With Type 2 Diabetes and Depression: The Get It Study Pilot Randomized Controlled Trial.

Major depressive disorder is often comorbid with diabetes and associated with worse glycemic control. Exercise improves glycemic control and depression, and thus could be a parsimonious intervention for patients with comorbid diabetes and major depression. Because patients with diabetes and comorbid depression are often sedentary and lack motivation to exercise, we developed a group exercise intervention that integrates strategies from behavioral activation therapy for depression to increase motivation for and enjoyment of exercise. We conducted a 6-month pilot randomized controlled trial to test the feasibility of the behavioral activation exercise intervention (EX) for women with diabetes and depression. Of the 715 individuals who contacted us about the study, 29 participants were randomized to the EX condition or an enhanced usual care condition (EUC), which represents 4.1% of participants who initially contacted us. Inclusion criteria made recruitment challenging and limits the feasibility of recruiting women with diabetes and depression for a larger trial of the intervention. Retention was 96.5% and 86.2% at 3 and 6months. Participants reported high treatment acceptability; use of behavioral activation strategies and exercise class attendance was acceptable. No condition differences were observed for glycemic control, depressive symptoms, and physical activity, though depressive symptoms and self-reported physical activity improved over time. Compared to participants in the EUC condition, participants in the EX condition reported greater exercise enjoyment and no increase in avoidance behavior over time. Using behavioral activation strategies to increase exercise is feasible in a group exercise setting. However, whether these strategies can be delivered in a less intensive manner to a broader population of sedentary adults, for greater initiation and maintenance of physical activity, deserves further study.

Bidirectional-Compounding Effects of Rumination and Negative Emotion in Predicting Impulsive Behavior: Implications for Emotional Cascades.

Influenced by chaos theory, the emotional cascade model proposes that rumination and negative emotion may promote each other in a self-amplifying cycle that increases over time. Accordingly, exponential-compounding effects may better describe the relationship between rumination and negative emotion when they occur in impulsive persons, and predict impulsive behavior. Forty-seven community and undergraduate participants who reported frequent engagement in impulsive behaviors monitored their ruminative thoughts and negative emotion multiple times daily for two weeks using digital recording devices. Hypotheses were tested using cross-lagged mixed model analyses. Findings indicated that rumination predicted subsequent elevations in rumination that lasted over extended periods of time. Rumination and negative emotion predicted increased levels of each other at subsequent assessments, and exponential functions for these associations were supported. Results also supported a synergistic effect between rumination and negative emotion, predicting larger elevations in subsequent rumination and negative emotion than when one variable alone was elevated. Finally, there were synergistic effects of rumination and negative emotion in predicting number of impulsive behaviors subsequently reported. These findings are consistent with the emotional cascade model in suggesting that momentary rumination and negative emotion progressively propagate and magnify each other over time in impulsive people, promoting impulsive behavior.

A perfect storm: examining the synergistic effects of negative and positive emotional instability on promoting weight loss activities in anorexia nervosa.

Growing evidence indicates that both positive and negative emotion potentially influence the development and maintenance of anorexia nervosa, through both positive and negative reinforcement of weight loss activities. Such reactive emotional experience may be characterized by frequent and intense fluctuations in emotion, a construct known as "emotional instability." The purpose of this study was to investigate the association between positive emotional instability and weight loss activities in anorexia nervosa, and to investigate the synergistic effects of positive and negative emotional instability on promoting weight loss activities. Using ecological momentary assessment methods, 118 participants with anorexia nervosa reported their emotional experiences and behaviors at least six times daily over 2 weeks using a portable digital device. Using generalized linear modeling, results indicated that high levels of both positive and negative emotional instability, and the interaction between the two, were associated with more frequent weight-loss activities, beyond anorexia subtype and mean levels of emotional intensity. These findings indicate that when women with anorexia exhibit both high levels of both positive and negative emotional instability they are more prone to a variety of weight loss activities. The importance of addressing the role of both positive and negative emotion in anorexia treatment is discussed.