Abstract
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=35kg/m2) and 51 adults without HIV (BMI=36kg/m2) completed retrospective assessments of lifetime perceived weight stigma experiences/internalization. Next, participants were invited to complete an optional two-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.
Keywords: Weight bias, HIV, Stigma, Overweight, EMA
Introduction
Weight stigma, defined as the social devaluation of individuals based on body weight, affects over 40% of U.S. adults across all weight categories [1]. Individuals with overweight/obesity are common targets of weight stigma based on stereotypes attributing obesity to laziness or lack of willpower [1]. Weight stigma experiences can include instances of overt unfair treatment, such as harassment or prejudice, or more subtle devaluation, such as being glared at or avoided. Experiencing weight stigma is linked to heightened physiological stress [2], avoidance of future situations where stigma is anticipated [e.g., healthcare; 3], and may lead to downstream health consequences including depression [4], weight gain [5], and cardiometabolic disease risk [6]. Importantly, these associations exist independent of body weight [6], suggesting that weight stigma is pernicious beyond any effects of body weight alone.
Weight stigma can also manifest in the form of internalized weight stigma or “self-stigma”. This occurs when individuals internalize negative stereotypes about obesity and apply them to themselves, contributing to feelings of shame and self-reproach [7]. Internalized weight stigma is prevalent, with high levels endorsed by about half of adults with obesity [8], and it is associated with heightened risk for eating pathology [9], low self-esteem [10], exercise avoidance [11], and metabolic syndrome [12]. The potential clinical relevance of internalized weight stigma is underscored by recent work showing that internalizing weight stigma may have even stronger associations with negative health outcomes than experiencing weight stigma [10]. Internalizing weight stigma may partially mediate the link between experiencing weight stigma and negative health outcomes [11], suggesting that stigma internalization has crucial implications for health.
Despite the striking effects of weight stigma in the general population, limited research has examined weight stigma among people living with HIV (PLWH). One potential reason is that obesity is a fairly “new” problem in this population [13]. Historically, HIV has been associated with low body weight due to “wasting” syndrome, a symptom of HIV causing unintentional weight loss and signaling disease progression [14]. The introduction of modern anti-retroviral therapies (ART) has revolutionized HIV treatment and improved the lifespan of PLWH, yet this has also provided a window for chronic conditions like obesity to develop via traditional risk factors [e.g., diet, genetics, physical inactivity; 15, 16]. ART itself is also associated with metabolic dysregulation and in many cases, weight gain [17]. The past two decades have seen a steady rise in obesity rates among PLWH, with obesity now affecting as many as 35% of PLWH in the U.S., similar to rates found in the general population [18, 19].
Despite high rates of obesity in PLWH, we are only aware of two studies examining weight stigma in this group. In a qualitative study of intersectional stigma [20], women with HIV endorsed experiencing weight stigma at the structural, community, and interpersonal levels. Another study [21] examined how body size influences weight stigma among 671 PLWH, revealing that PLWH with overweight/obesity reported higher mean levels of experienced and internalized weight stigma than those of normal/underweight status. However, neither study examined how weight stigma in PLWH compared to adults of similar body weight without HIV. Additionally, both studies included PLWH across the weight spectrum, making it difficult to identify how HIV and obesity interact to influence weight stigma.
Investigating weight stigma in PLWH is critical because the stigma literature points to two potential hypotheses about weight stigma in PLWH that have starkly different health implications for this group. On the one hand, research has shown that holding multiple stigmatized identities has additive negative effects on health [22]. For example, individuals who belong to multiple marginalized groups (e.g., Black women) often report more frequent stigma experiences and greater health consequences than both those who are not marginalized (e.g., White men) and those with one source of marginalization [e.g., Black men; 22, 23]. This suggests that, compared to adults in the general population, weight stigma and its effects may be more potently experienced by PLWH and obesity who already face HIV stigma.
Yet recent work also points to an alternative possibility that PLWH and obesity may be less, not more, vulnerable to weight stigma than the general population [21]. Given historical conceptions of HIV as a “wasting” disease, PLWH may be more accepting of overweight/obesity because it may be perceived as a sign of health in the context of HIV [24, 25] and/or as a normative consequence of ART [26, 27]. Further, HIV is a highly stigmatized yet concealable condition, and excess weight may reduce the visibility of HIV status and allow PLWH to control disclosure and reduce potential future stigma [21, 28]. Indeed, many PLWH and obesity perceive themselves to be normal weight or underweight, possibly reflecting more positive attitudes about obesity or a higher desired weight [21, 26, 29]. Perception of oneself as having obesity is predictive of weight stigma regardless of objective body size [2], suggesting that PLWH may be a lower risk for weight stigma than their peers without HIV.
To address these gaps in the literature, the goals of this exploratory study were to examine whether levels of perceived weight stigma experiences and internalized weight stigma differed between adults with obesity with versus without HIV when assessed via one-time retrospective reports (Aim 1) and momentary reports in daily life collected via Ecological Momentary Assessment (EMA; Aim 2).
Methods
Participants completed a one-time electronic survey assessing perceived lifetime experienced and internalized weight stigma. Participants were then invited to complete an optional two-week EMA study wherein participants used a smartphone to complete brief daily assessments of momentary experienced and internalized weight stigma multiple times daily as they went about their lives. EMA was leveraged because it improves ecological validity, reduces recall biases, and improves data specificity and granularity [30]. EMA methods are time-intensive and recruiting the hidden population of PLWH can be challenging [31], so the EMA portion of the study was optional to maximize the sample that completed retrospective surveys.
Participants
Participants were adults with and without HIV with a self-reported BMI≥30kg/m2 and who were ≥18 years of age. Given the study design, individuals were required to own/use a smartphone and have internet access to participate. Individuals were not invited to participate if they did not speak English fluently or if they reported a history of a psychotic disorder, factors that may impair ability to provide informed consent. Individuals who reported sleeping ≥25% of the time between 9:00AM-9:30PM (e.g., due to night shift work) were excluded due to potential interference with EMA procedures. Because a broader aim of this study involved assessing momentary eating behaviors, individuals were not invited to participate if they were currently pregnant or had a history of weight loss surgery, factors likely to affect self-reported eating.
Procedures
Study procedures were approved by the Institutional Review Board at The Miriam Hospital. Participants were recruited via advertisements posted in the local community and online that read, “Seeking adults [with HIV] for participation in a smartphone research study.” We also recruited PLWH through a local Immunology clinic where a research assistant pre-screened patients using electronic medical records to identify individuals with an HIV diagnosis and BMI ≥30kg/m2. Potentially eligible patients received study information and were invited to complete an online eligibility survey. Eligible individuals were invited to complete an electronic consent form, with the option to consent to participate in the one-time retrospective survey alone or in combination with the two-week EMA study. Participants answered questions to confirm their understanding of the consent form and provided identification to confirm their name and age. Electronic data collection was completed using REDCap (Research Electronic Data Capture) [32].
Consented participants completed a 30–60 minute one-time electronic survey. Compensation was a $20 electronic gift card. Next, participants who opted to complete the EMA protocol viewed an online orientation video describing the study’s EMA procedures, including definitions of stigmatizing events, and downloaded the smartphone application hosted by LifeData [33]. Beginning the next day, the smartphone application prompted participants to complete assessments of momentary weight stigma five times daily for two weeks. Participants were prompted to complete entries via an on-screen notification from LifeData five times randomly from 9:00AM-9:30PM, with prompts occurring at least 2 hours apart. Prompts not answered within 60 minutes of receipt counted as missing data, per standard practice in EMA research [34]. Participants received $1 for each completed EMA prompt and an additional $10 if they completed ≥85% of prompts.
Baseline (Trait) Measures
Demographics.
Participants self-reported their assigned sex at birth, gender identity (i.e., male, female, transgender, something else), sexual orientation (e.g., straight/heterosexual, gay/lesbian/homosexual, bisexual, something else), age, racial and ethnic background, and socioeconomic status (i.e., education level).
HIV Status.
Participants self-reported whether they had ever received an HIV diagnosis. For a subset of participants, electronic medical records were used to identify individuals with an HIV diagnosis as part of targeted recruitment efforts.
Body Mass Index (BMI).
Participants self-reported their height (inches) and weight (pounds), which were used to calculate BMI (kg/m2). For a subset of participants with HIV recruited at a local Immunology clinic, BMI was confirmed via electronic medical records.
Perceived Weight Status.
Participants’ perceived weight status was assessed by asking participants to describe their weight on the following scale: a little underweight, normal weight, a little overweight, somewhat overweight, and extremely overweight. Similar scales have been used to assess body size perceptions in prior work [35].
Weight Stigma Measures
Lifetime Experiences of Weight Stigma.
One item assessed whether participants had ever experienced weight stigma in their lifetime. Participants were asked, “Have you ever been teased, judged, criticized, or treated unfairly because of your weight?” (Yes/No). Those answering yes were coded as having experienced weight stigma. This measure has been used to assess lifetime exposure to stigma in prior work [36].
The 10-item Stigmatizing Situations Inventory-Brief [SSI-B; 37, 38] was used to assess the frequency of lifetime weight stigma events on a scale from 0 (never) to 9 (daily) using one global score. A sample item includes, “Overhearing other people making rude remarks about you in public [due to your weight].” Reliability in this study was good (α = 0.90). This measure is a widely used weight stigma assessment [39], yet in prior work this scale has yielded low means [4, 37] and participants have had difficulty rating weight stigma frequency on the 10-point Likert scale [40]. Thus, we included a second experienced weight stigma measure.
The 19-item Distressing Interpersonal Interactions Scale [DIIS; 41] assessed the frequency of lifetime experiences of weight stigma on scale from 1 (never) to 4 (often). A sample item includes, “You are treated with less courtesy than other people because of your weight.” Reliability in this study was excellent (α = 0.97). This scale has been used in prior work to assess weight stigma events [42].
Internalized Weight Stigma.
The 10-item Modified Weight Bias Internalization Scale [WBIS; 7, 43, 44] assessed the extent to which individuals apply negative societal beliefs about obesity to themselves using a scale from 1 (strongly disagree) to 7 (strongly agree). A sample item includes, “I hate myself for my weight.” Reliability in this study was good (α = 0.92). The scale has been widely used to assess internalized weight stigma among adults with obesity [45].
EMA (State) Measures
Frequency and Characteristics of Weight Stigma.
Momentary stigma events were assessed at every EMA prompt using 10 items that were adapted from prior momentary stigma measures [46–48]. Participants were shown a list of different types of stigmatizing events and were asked, “Have you experienced any stigmatizing events since the last prompt?” (Yes/No). Participants who endorsed stigma were asked follow-up questions about the stigma event(s). Participants reported the number of stigma events they experienced since the last EMA prompt and the reason(s) they were stigmatized using a checklist including weight and other reasons, with the option to select multiple reasons. Stigmatizing events indicating “weight” as a reason for stigma were coded as a weight stigma events. Participants reported the intensity of weight stigma events on a scale from 1 (mild) to 10 (severe) and their emotional response to weight stigma events on a scale from 1 (this event made me feel good) to 5 (this event upset me extremely). Participants used checklists (see Table 5 for response options) to report the form, location, and source of weight stigma events.
Table 5.
Descriptive statistics on the characteristics of weight stigma events in daily life among adults with obesity across the full sample and by HIV status.
| Full Sample (N = 67) |
Adults with obesity without HIV (n = 39) |
Adults with obesity with HIV (n = 28) |
|
|---|---|---|---|
| Participants reporting weight stigma events (%) | 28% | 33% | 21% |
| Total no. of EMA prompts where weight stigma was reported (out of 4405 total EMA prompts) | 41 | 33 | 8 |
| Intensity of weight stigma (scale: 1–10; 10=severe) (M ± SD) | 4.59 ± 2.14 | 4.48 ± 2.09 | 5.00 ± 2.45 |
| Emotional response to weight stigma (scale: 1–5; 5=this event upset me extremely) (M ± SD) | 3.63 ± 0.83 | 3.61 ± 0.79 | 3.75 ± 1.04 |
| Percentage of weight stigma events where other reasons for stigma were concurrently reported (%) | |||
| HIV status | 10% | 0% | 50% |
| Sexual orientation | 7% | 0% | 38% |
| Gender | 7% | 3% | 25% |
| Race | 7% | 6% | 13% |
| Social status | 7% | 3% | 25% |
| Age | 7% | 6% | 13% |
| Mental health condition | 7% | 0% | 38% |
| Physical health condition | 5% | 3% | 13% |
| Disability | 2% | 0% | 13% |
| Other | 5% | 6% | 0% |
| Number of reasons for stigma (e.g., weight, HIV) reported at EMA prompts where weight stigma was reported (M ± SD) | 1.65 ± 1.44 | 1.27 ± 0.57 | 3.25 ± 2.60 |
| Location of weight stigma (% of weight stigma events) | |||
| Work | 17% | 18% | 13% |
| Home | 20% | 12% | 50% |
| Healthcare setting | 2% | 3% | 0% |
| Restaurant/bar | 15% | 18% | 0% |
| Public transportation | 7% | 9% | 0% |
| Other public setting | 34% | 36% | 25% |
| Other | 15% | 9% | 38% |
| Source of weight stigma (% of weight stigma events) | |||
| Stranger | 42% | 42% | 38% |
| Store worker/owner | 10% | 12% | 0% |
| Co-worker/supervisor | 12% | 15% | 0% |
| Healthcare professional | 5% | 6% | 0% |
| Friend | 10% | 6% | 25% |
| Spouse/partner/family member | 10% | 9% | 13% |
| Acquaintance | 2% | 0% | 13% |
| Social media/Environmental barrier | 12% | 15% | 0% |
| Other | 15% | 12% | 25% |
| Type of weight stigma event (% of weight stigma events) | |||
| Treated with less courtesy/respect | 27% | 18% | 63% |
| Made fun of/teased/called names | 10% | 9% | 13% |
| Glared at/singled out | 15% | 18% | 0% |
| Treated unfairly/prevented from doing something | 12% | 6% | 38% |
| Treated as if others think I am dishonest/immoral | 5% | 0% | 25% |
| Made to feel inferior/less smart/capable than others | 12% | 12% | 13% |
| Excluded/ignored | 12% | 6% | 28% |
| Harassed/threatened | 5% | 0% | 25% |
| Treated as if others are afraid/ashamed of me | 5% | 0% | 25% |
| Others judged/criticized/made assumptions about me | 17% | 15% | 25% |
| Singled out by the environment | 2% | 3% | 0% |
| Overheard disparaging comments about people like me | 20% | 21% | 13% |
| Received poorer service than others | 12% | 12% | 13% |
| Felt stigmatized in another way | 15% | 3% | 63% |
| Still reacting to stigma earlier today | 15% | 12% | 25% |
Internalized Weight Stigma.
Two items assessed internalized weight stigma at every EMA prompt, including: (1) “Since the last prompt, I’ve felt anxious about my weight because of what people might think of me” and (2) “Since the last prompt, I’ve wished I could drastically change my weight.” Items were rated on a scale from 1 (strongly disagree) to 7 (strongly agree) and are derived from a widely-used trait measure, the Modified WBIS [43]. The items were averaged at every prompt to create a mean momentary score. The nature of EMA necessitates brief assessments, and because we were not aware of any prior studies to assess momentary internalized weight stigma via EMA, we selected two items from the WBIS that we believed based upon our clinical expertise would be likely to fluctuate over time and would translate well to momentary assessment. Participants’ average levels of lifetime and momentary internalized weight stigma scores were strongly correlated (r = 0.74, p < 0.001), suggesting good correspondence between the trait and state measures.
Data Analytic Strategy
Analyses were conducted using SPSS Statistics Version 26.0. Compliance to the EMA protocol was determined by dividing the number of completed EMA prompts by the total number of EMA prompts delivered (i.e., 70), and individuals with <40% compliance were excluded from data analysis [n=3; 49]. Chi-square analyses (i.e., categorical variables with cell sizes >5), Fisher’s exact tests (i.e., categorical variables with cell sizes ≤5), and one-way ANOVAs (i.e., continuous variables) were used to determine if there were any significant differences in demographic variables (e.g., age, sex, sexual orientation) or variables related to outcomes of interest (e.g., BMI) between PLWH versus those without HIV. Similar methods were used to identify potential demographic differences based on study enrollment (i.e., whether participants chose to enroll in the EMA study) as well as compliance to the EMA protocol. Variables that differed significantly across groups were included as covariates in analyses.
Non-multilevel generalized linear models (GLMs) were used to examine whether levels of retrospective- and naturalistically-assessed weight stigma experiences and internalization differed based on HIV status. For outcome variables with normal distributions, GLMs with a normal distribution and identity link function were used. For outcome variables with count distributions (e.g., total number of weight stigma events during the EMA period), a Poisson distribution and log link function was used. For outcome variables with positively skewed distributions (e.g., measures of lifetime weight stigma experiences), a gamma distribution and log link function were used. Within each model, effect sizes can be interpreted as odds ratios (ORs), with adults with obesity without HIV serving as the reference group against which PLWH were compared. Due to sample size limitations, the effect of HIV status on each dependent variable was examined in a separate model to preserve statistical power.
Results
Aim 1: Retrospectively-assessed Weight Stigma in Adults with Obesity with and without HIV
Full demographic information is provided in Table 1. In brief, 101 adults with obesity participated, including 50 adults reporting an HIV diagnosis and 51 reporting no history of HIV. On average, the sample was 46 years old with a self-reported BMI of 36kg/m2. Most participants (59%) were assigned male at birth and identified as heterosexual/straight (61%) or gay/homosexual (34%). Participants identified their racial/ethnic background as White (55%), Hispanic/Latinx (18%), or Black (15%). Participants described their weight as somewhat overweight (47%) or extremely overweight (27%). Among PLWH, 94% reported current ART medication use. Most (62%) reported having an HIV diagnosis for >10 years, with 100% being diagnosed >1 year ago.
Table 1.
Participant characteristics
| Full Sample N = 101 |
Adults with obesity without HIV n = 51 |
Adults with obesity with HIV n = 50 |
Pearson Chi Square | |
|---|---|---|---|---|
| Biological sex (%) | χ2 = 0.87 | |||
| Male | 59% | 55% | 64% | |
| Female | 41% | 45% | 36% | |
| One-way ANOVA | ||||
| Age (M ± SD) | 46.4 ± 11.5 | 45.3 ± 11.8 | 47.4 ± 11.3 | F = 0.83 |
| Self-reported BMI (M ± SD) | 35.8 ± 5.6 kg/m2 | 36.4 ± 6.3 kg/m2 | 35.1 ± 4.9 kg/m2 | F = 1.46 |
| Fisher’s Exact Test | ||||
| Race/ethnicity (%) | Fisher’s Exact = 7.24 | |||
| White, non-Hispanic | 55% | 61% | 50% | |
| Asian | 4% | 6% | 2% | |
| Black/African American/Caribbean | 15% | 12% | 18% | |
| Hispanic/Latino | 18% | 18% | 18% | |
| More than one race | 4% | 0% | 8% | |
| Other | 4% | 4% | 4% | |
| Sexual orientation (%) | Fisher’s Exact = 14.35** | |||
| Straight/heterosexual | 61% | 76% | 46% | |
| Gay/lesbian/homosexual | 34% | 20% | 48% | |
| Something else (e.g., bisexual) | 5% | 4% | 6% | |
| Education level (%) | Fisher’s Exact = 21.50** | |||
| High school or less | 26% | 12% | 40% | |
| Bachelors/Associates/Some college | 48% | 51% | 46% | |
| Graduate/Some graduate | 26% | 37% | 14% |
Notes: M, mean; SD, standard deviation; BMI, body mass index.
p < .05,
p < .01,
p < .001. Covariates in all models included sex, age, race, socioeconomic status, sexual orientation, and BMI.
As presented in Table 1, when examining demographic differences between adults with versus without HIV, sexual orientation and socioeconomic status (i.e., education level) differed based on HIV status and were included as covariates in all analyses. Age, sex, race, and BMI did not differ based on HIV status, but these factors were included as covariates to increase confidence that differences in dependent variables are due to HIV status alone. Outlined in Table 2, perceived weight status also differed based on HIV status, with PLWH tending to perceive themselves as less overweight than their BMI-matched counterparts without HIV. Whereas most PLWH perceived themselves to be “a little” or “somewhat” overweight, most adults without HIV perceived themselves to be “somewhat” or “extremely” overweight. This was seen across BMI categories; for example, among adults with Class I obesity (i.e., BMI=30–34.99kg/m2), 48% of PLWH perceived themselves to be either a little underweight, normal weight, or a little overweight compared to 28% of adults without HIV.
Table 2.
Self-reported perceived weight status by HIV status and BMI category among adults with obesity
| DIFFERENCES IN PERCEIVED WEIGHT STATUS BASED ON HIV STATUS | |||||
|---|---|---|---|---|---|
| Adults with obesity without HIV n = 51 |
Adults with obesity with HIV n = 50 |
Fisher’s Exact Test | |||
| Perceived weight status (%) | Fisher’s Exact = 10.14* | ||||
| A little underweight/Normal weight | 4% | 6% | |||
| A little overweight | 12% | 30% | |||
| Somewhat overweight | 47% | 48% | |||
| Extremely overweight | 37% | 16% | |||
| DESCRIPTIVE DATA ON PERCEIVED WEIGHT STATUS BY BMI CATEGORY AND HIV STATUS | |||||
| Adults with obesity without HIV n = 51 |
Adults with obesity with HIV n = 50 |
||||
| Class I Obesity (n=28) | Class II Obesity (n=23) | Class I Obesity (n=31) | Class II Obesity (n=19) | ||
| Perceived weight status (%) | |||||
| A little underweight/Normal weight | 7% | 0% | 6% | 5% | |
| A little overweight | 21% | 0% | 42% | 11% | |
| Somewhat overweight | 50% | 43% | 45% | 53% | |
| Extremely overweight | 21% | 57% | 6% | 32% | |
Notes: BMI, body mass index. Class I Obesity, BMI=30–34.99kg/m2; Class II Obesity, BMI≥35kg/m2.
As presented in Table 3, GLMs revealed that levels of retrospectively-assessed internalized weight stigma were not statistically different based on HIV status (Wald χ2= 0.40; p > 0.05), with similar levels reported by PLWH (Estimated Marginal Mean [EMMWBIS] = 4.23) and adults without HIV (EMMWBIS = 4.02). On a single-item measure, fewer PLWH (56%) reported lifetime perceived weight stigma experiences relative to their counterparts without HIV (82%; χ2= 8.24, p < 0.01). On measures assessing lifetime frequency of weight stigma events, participants on average reported experiencing weight stigma “rarely” (MDIIS = 1.71 ± 0.74) or about “once” to “several times in your life” (MSSI = 1.45 ± 1.52). GLMs showed that average levels of lifetime perceived weight stigma events were 1.2 times lower among PLWH (EMMDIIS = 1.51) compared to adults without HIV (EMMDIIS = 1.84; Wald χ2= 5.67; p < 0.05, OR = 0.82). Using the SSI-B, there was a similar trend toward lower lifetime perceived weight stigma events in PLWH (EMMSSI-B = 1.05) compared to adults without HIV (EMMSSI-B = 1.40), but it was not a statistically significant difference (Wald χ2= 1.13; p = 0.29).
Table 3.
Generalized linear models examining cross-sectional associations between HIV status and retrospectively-assessed weight stigma experiences and internalization (Aim 1).
| AIM 1 OUTCOMES (BASELINE-MEASURED) | |||||||
|---|---|---|---|---|---|---|---|
| Variables | EMMs (SE) | B | SE | df | Wald Chi Square | p | OR |
| Internalized weight stigma (WBIS; scale: 1–7) | |||||||
| Adults with obesity – no HIV diagnosis (n=51) |
4.02 (0.22) | reference | |||||
| Adults with obesity – HIV diagnosis (n=50) |
4.23 (0.22) | 0.21 | 0.33 | 1, 93 | 0.40 | 0.53 | 1.05 |
| Lifetime weight stigma experiences (SSI-B; scale: 0–9) | |||||||
| Adults with obesity – no HIV diagnosis (n=51) |
1.40 (0.25) | reference | |||||
| Adults with obesity – HIV diagnosis (n=50) |
1.05 (0.19) | −0.29 | 0.27 | 1, 93 | 1.13 | 0.29 | 0.75 |
| Lifetime weight stigma experiences (DIIS; scale: 1–4) | |||||||
| Adults with obesity – no HIV diagnosis (n=51) |
1.84 (0.10) | reference | |||||
| Adults with obesity – HIV diagnosis (n=50) |
1.51 (0.08) | −0.19 | 0.08 | 1, 93 | 5.67 | 0.02* | 0.82 |
Notes: Covariates in all models included biological sex, age, race, socioeconomic status, sexual orientation, and BMI.
p < .05,
p < .01,
p < .001.
EMM, Estimated Marginal Means; SE, Standard Error; df, degrees of freedom; OR, Odds Ratio; DIIS, Distressing Interpersonal Interactions Scale; SSI-B, Stigmatizing Situations Inventory – Brief; WBIS, Weight Bias Internalization Scale.
Aim 2: Naturalistically-assessed Weight Stigma in Adults with Obesity with and without HIV
A majority of participants who completed the one-time retrospective assessments also opted to complete the EMA protocol (74%), although a significantly greater proportion of adults without HIV (84%) opted to complete the EMA study relative to PLWH (66%; χ2 = 4.55, p < 0.05). Of those who began the EMA study, 3 participants withdrew during the EMA period due to unanticipated adherence barriers (e.g., work/family responsibilities), 2 did not complete the EMA protocol, and 3 did not meet the EMA adherence threshold and were excluded from analysis. These 8 participants reported lower levels of retrospectively-assessed internalized weight bias (M = 3.1) than EMA completers (M = 4.3; F = 4.9, p < 0.05), but they reported similar levels of experienced weight stigma on the SSI-B (M=1.5 vs. =1.7; F = 0.08. p > 0.05) and on the DIIS (M = 1.8 vs. 1.8; F = 0.02, p > 0.05). Concerns are mitigated because 50% of these 8 participants were PLWH, suggesting no differential attrition based on HIV status.
Among those who were included in EMA data analysis, participants completed 3971 prompts of 4690 delivered (85%), with 85% of participants completing ≥70% of prompts (i.e., good adherence). On average, EMA prompts were completed within 11±14 minutes of receipt and 89% were completed within 30 minutes. A one-way ANOVA indicated that adherence to the EMA protocol did not differ between individuals with and without HIV (F(1, 66)=1.31, p>0.05). Regardless, EMA compliance was included as a covariate in Aim 2 analyses of daily weight stigma given potential for weight stigma levels to be influenced by EMA compliance rate. Further, Aim 2 analyses also controlled for BMI, age, sex, race, sexual orientation, and socio-economic status.
As seen in Table 4, GLMs revealed that mean levels of internalized weight stigma in daily life trended higher among PLWH (EMM = 4.48) relative to those without HIV (EMM = 3.86), but the effect did not achieve statistical significance (Wald χ2= 2.85; p = 0.09). A total of 41 perceived weight stigma events were reported across all participants in daily life, with 28% of participants reporting ≥1 weight stigma event during the EMA period (range = 0–10 events/participant). PLWH reported 2.8 times fewer momentary weight stigma events during the two-week EMA period (EMM = 0.20 events) relative to adults without HIV (EMM = 0.57; Wald χ2= 4.74; p < 0.05, OR = 0.35). Perceived weight stigma events were reported by 21% of PLWH, who reported eight total events (range = 0–2), compared to 33% of adults without HIV, who reported 33 events (range = 0–10).
Table 4.
Generalized linear models examining longitudinal associations between HIV status and naturalistically-assessed weight stigma experiences and internalization during the EMA period (Aim 2).
| AIM 2 OUTCOMES (EMA-MEASURED) | |||||||
|---|---|---|---|---|---|---|---|
| Variables | EMMs (SE) | B | SE | df | Wald Chi Square | p | OR |
| Mean levels of internalized weight stigma during EMA (scale: 1–7) | |||||||
| Adults with obesity – no HIV diagnosis (n=39) |
3.86 (0.21) | reference | |||||
| Adults with obesity – HIV diagnosis (n=28) |
4.48 (0.26) | 0.62 | 0.36 | 1, 59 | 2.85 | 0.09 | 1.16 |
| Total number of weight stigma events reported during EMA | |||||||
| Adults with obesity – no HIV diagnosis (n=39) |
0.57 (0.14) | reference | |||||
| Adults with obesity – HIV diagnosis (n=28) |
0.20 (0.08) | −1.02 | 0.47 | 1, 59 | 4.74 | 0.03* | 0.35 |
Notes: Covariates in all models included biological sex, age, race, socioeconomic status, sexual orientation, and BMI.
p < .05,
p < .01,
p < .001.
EMM, Estimated Marginal Means; SE, Standard Error; df, degrees of freedom; OR, Odds Ratio; EMA, Ecological Momentary Assessment.
Data on the characteristics of momentary weight stigma events in daily life by HIV status are presented in Table 5 . Among participants who reported a perceived weight stigma event during EMA, 95% were slightly bothered, upset, or extremely upset by the event. Weight stigma events commonly involved being treated with less respect (27% of events) and occurred in a public setting (34% of events) or at home (20%), with the most typical source being strangers (42% of events). During weight stigma events, participants often perceived being stigmatized because of their weight and another reason, with PLWH reporting an average of 3.25 perceived reasons for stigma compared to adults without HIV (1.27 reasons). Co-occurring reasons for stigma included HIV status (10% of weight stigma events), sexual orientation (7%), and race (7%).
Discussion
This study is one of the first to document weight stigma levels in PLWH and obesity, an important first step in understanding the extent to which weight stigma adds to health burden in PLWH and obesity who are already at heightened risk for poor physical and mental health [50]. Study results demonstrated that in a sample of adults with obesity, PLWH reported fewer perceived weight stigma events both retrospectively and in daily life than their counterparts without HIV. Yet they endorsed internalized weight stigma equally across retrospective and momentary assessments. Importantly, the groups were matched on BMI, and analyses controlled for potential effects of BMI. These findings have key implications for understanding the phenomenology of weight stigma and its impact on health in PLWH and obesity.
Study findings suggest that perceptions of weight stigma experiences may differ between adults with versus without HIV, with HIV status having a potential buffering effect against perceived weight stigma experiences. Potential explanations are that, due to historical links between HIV status and low body weight, PLWH may be more likely to view a heavier body weight as a sign of health in the context of HIV [25], as a normative consequence of ART [27], and/or as a factor that reduces visibility and potential disclosure of HIV status [28], resulting in a more positive attribution of overweight status that blunts weight stigma sensitivity. Prior research also suggests that PLWH and overweight/obesity are more likely to underestimate their body weight category than adults without HIV [21, 26, 29, 51], a phenomenon we observed in the current study. Given data showing that body size perception is related to weight stigma risk independent of BMI [2], weight misperception may contribute to reduced perception of weight stigma among PLWH and obesity. Future research is needed to investigate PLWH’s cognitive processes (i.e., perceptions, cognitions) related to weight stigmatizing situations and weight/body size to better understand what factors may contribute to differential perception of weight stigma events among PLWH.
Despite endorsing less frequent perceived weight stigma from others, PLWH reported similar levels of retrospectively- and naturalistically-assessed internalized weight stigma compared to adults without HIV, with both groups showing levels of internalized weight stigma comparable to norms in the general population of adults with obesity [8, 43]. Strikingly, weight stigma internalization levels were similar between groups even though PLWH in this sample tended to perceive themselves to be less overweight than did adults without HIV. This suggests that weight stigma internalization may occur at a lower perceived weight threshold for PLWH, underscoring the need for more research on internalized weight stigma in this population. Another implication of this finding is that anti-obesity messages are so pervasive that perceived weight stigma experiences may not be necessary for developing internalized weight stigma [8], adding to a growing body of literature distinguishing internalized and experienced weight stigma and their effects on health [10, 11]. Not only is internalized weight stigma a more potent driver of negative health effects than weight stigma experiences [10, 11] in the general population, but it is linked to risk for metabolic syndrome [12] and obesogenic behaviors (i.e., eating pathology [9], exercise avoidance [11]) that may exacerbate poor health outcomes in PLWH who already face high rates of obesity and cardiometabolic disease [16]. Internalized weight stigma is an ideal target for intervention because it is clinically relevant and modifiable [45, 52]. Efficacious approaches for reducing internalized weight stigma include cognitive-behavioral therapy [52], compassion-focused therapy [53], and expressive writing [54] interventions.
This study also showed that during weight stigma events in daily life, PLWH reported being stigmatized for an average of over 3 reasons (i.e., they were stigmatized due to weight and at least two other reasons), while adults without HIV reported being stigmatized for just over one reason (i.e., weight). Although this point should not be over-interpreted given the low incidence of weight stigma among PLWH in this sample, it is well-established that PLWH not only face HIV stigma, but they are overrepresented among racial, sexual, and socioeconomic minority groups [50, 55] and display greater engagement in stigmatized behaviors like smoking, substance use, and risky sex [56, 57]. In prior studies, PLWH have reported that it can be “difficult to disentangle” discrete sources of stigma given multiple potential sources of marginalization [20]. Thus, it is plausible that weight stigma may be more likely to intersect with other sources of stigma in PLWH and obesity, compared to those without HIV. It is critical for future research to examine intersecting sources of stigma in PLWH, their effect on health, and how interventions for PLWH can foster resilience and coping relevant to diverse forms of stigma.
One useful framework for exploring this finding in future research is intersectionality theory [58]. Rather than viewing each marginalized identity as discrete, intersectionality examines how multiple social identities (e.g., weight, HIV status) converge within individuals to influence social position, stigma, and health [23, 59]. In future research, qualitative studies may be particularly useful for exploring intersectional stigma in PLWH and obesity [20], including how HIV status influences body size perception, attributions of obesity, and links between obesity and health.
Strengths and Limitations
This study was among the first EMA studies to examine weight stigma in adults with obesity and HIV. Results provided two sources of data (retrospective, naturalistic) that yielded corresponding results, and the study used validated weight stigma measures (i.e., SSI-B, WBIS). The inclusion of a comparison group of adults with obesity without HIV was advantageous for examining how weight stigma may or may not be unique among PLWH. Finally, this study was among the first to examine weight stigma in PLWH and obesity, the group with the greatest weight stigma risk [1].
This study also had limitations. Given its pilot nature and the inherent challenges of recruiting PLWH and obesity, a modestly-sized convenience sample was utilized. Despite this, the sample was reasonably diverse in biological sex, racial/ethnic background, and age. However, low statistical power precluded a more nuanced examination of how weight stigma may differ based on these demographic factors. Further, due to the online nature of this study, self-reports were used to assess BMI, and for some participants, HIV status. These factors limit our ability to generalize results from this study to a large proportion of PLWH and underscores the need for larger, more representative studies to examine the prevalence and characteristics of weight stigma among PLWH.
Additionally, given the novel nature of EMA methodology, there is no consensus on gold-standard momentary weight stigma measurements [60]. In this study, the frequency of momentary perceived weight stigma events (M=0.04 events/participant/day) was low relative to rates in some EMA studies of adults with obesity [M = 0.79–3.08/events/participant/day; 46, 61] but not others [M = 0.02–0.11 events/participant/day; 60, 62]. Although our EMA measures were derived from validated trait measures, it is possible that momentary weight stigma frequency was underestimated in this study. Given that retrospective measures indicate that weight stigma is typically experienced several times in one’s lifetime [37], it is also possible that assessing experienced weight stigma for just two weeks may be inadequate to capture the true incidence of weight stigma. Future research is needed to determine the best measurement strategies for assessing weight stigma events in daily life.
Conclusions
Among adults with obesity in this sample, perceptions of weight stigma experiences differed between adults with versus without HIV, with HIV status having a potential buffering effect against perceived weight stigma experiences. However, levels of retrospectively- and naturalistically-assessed internalized weight stigma did not differ based on HIV status. This was true even though PLWH perceived themselves to be less overweight than adults without HIV, suggesting that PLWH may have a lower weight threshold for internalizing weight stigma. Given the potent negative health consequences of weight stigma, particularly when internalized by the individual, and the rising rates of obesity among PLWH, future research is needed to clarify how HIV and obesity intersect to influence weight stigma experiences, internalization, and their effects on health in PLWH.
Acknowledgements:
We wish to thank study participants for devoting their time and energy to participate in this research as well as our research team for assisting with data collection, including Bianca Obiakor and Deborah Good.
Funding:
This work was supported by the Dr. George A. Bray Research Scholars Award Fund, Department of Medicine, Warren Alpert Medical School of Brown University; The Miriam Hospital Immunology Center; The Providence/Boston Center for AIDS Research (CFAR; NIH grant P30AI042853); and training grants from the National Heart, Lung, and Blood Institute (T32HL076134), the National Institute on Minority Health and Health Disparities (K23MD015092), and the National Institute of Diabetes and Digestive and Kidney Diseases (K23DK124578).
Footnotes
Conflicts of Interest/Competing Interests: The authors have no conflicts of interest to declare that are relevant to the content of this article.
Ethics Approval: All study procedures were approved by the Institutional Review Board at the Miriam Hospital in Providence, Rhode Island. The procedures used in this study adhere to the tenets of the Declaration of Helsinki.
Consent to Participate: Informed consent was obtained from all individual participants included in the study.
Consent for Publication: Participants consented to the publication of their deidentified data for research purposes.
Code availability: Code is available upon request and based on the journal’s policies.
Availability of Data and Material:
Data is available upon request and based on the journal’s policies.
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Data Availability Statement
Data is available upon request and based on the journal’s policies.