The Adverse Effect of Weight Stigma on the Well-Being of Medical Students with Overweight or Obesity: Findings from a National Survey

The Adverse Effect of Weight Stigma on the Well-Being of Medical Students with Overweight or Obesity: Findings from a National Survey Sean M. Phelan, Ph.D., MPH1,10, Diana J. Burgess, Ph.D.2, Rebecca Puhl, Ph.D.3, Liselotte N. Dyrbye, M.D.1, John F. Dovidio, Ph.D.4, Mark Yeazel, M.D.5, Jennifer L. Ridgeway, MPP6, David Nelson, Ph.D.2, Sylvia Perry, Ph.D.7, Julia M. Przedworski, B.S.8, Sara E. Burke, MS, MPhil9, Rachel R. Hardeman, Ph.D., MPH2, and Michelle van Ryn, Ph.D., MPH1,10 1 College of Medicine, Mayo Clinic, Rochester, MN, USA; 2Center for Chronic Disease Outcomes Research, Minneapolis VAMC, Department of Medicine, University of Minnesota, Minneapolis, MN, USA; 3Rudd Center for Food Policy & Obesity, University of Connecticut, Hartford, CT, USA; 4 Department of Psychology, Yale University, New Haven, CT, USA; 5Department of Family Medicine, University of Minnesota, Minneapolis, MN, USA; 6 Mayo Clinic Division of Health Care Policy and Research, Rochester, MN, USA; 7Department of Psychological Science, University of Vermont, Burlington, VT, USA; 8Division of Health Policy and Management, University of Minnesota, Minneapolis, MN, USA; 9Department of Psychology, Yale University, New Haven, CT, USA; 10Mayo School of Medicine & Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN, USA. BACKGROUND: The stigma of obesity is a common and overt social bias. Negative attitudes and derogatory humor about overweight/obese individuals are commonplace among health care providers and medical students. As such, medical school may be particularly threatening for students who are overweight or obese. OBJECTIVE: The purpose of our study was to assess the frequency that obese/overweight students report being stigmatized, the degree to which stigma is internalized, and the impact of these factors on their well-being. DESIGN: We performed cross-sectional analysis of data from the Medical Student Cognitive Habits and Growth Evaluation Study (CHANGES) survey. PARTICIPANTS: A total of 4,687 first-year medical students (1,146 overweight/obese) from a stratified random sample of 49 medical schools participated in the study. MAIN MEASURES: Implicit and explicit self-stigma were measured with the Implicit Association Test and Anti-Fat Attitudes Questionnaire. Overall health, anxiety, depression, fatigue, self-esteem, sense of mastery, social support, loneliness, and use of alcohol/drugs to cope with stress were measured using previously validated scales. KEY RESULTS: Among obese and overweight students, perceived stigma was associated with each measured component of well-being, including anxiety (beta coefficient [b]=0.18; standard error [SE]=0.03; p<0.001) and depression (b=0.20; SE=0.03; p<0.001). Among the subscales of the explicit self-stigma measure, dislike of obese people was associated with several factors, including depression (b=0.07; SE =0.01; p<0.001), a lower sense of mastery (b=−0.10; SE=0.02; p<0.001), and greater likelihood of using drugs or alcohol to cope with stress (b=0.05; SE=0.01; p<0.001). Fear of becoming fat was associated with each measured component of well-being, including lower body esteem (b=−0.25; SE = 0.01; p<0.001) and less social support (b=−0.06; SE=0.01; p<0.001). Implicit selfstigma was not consistently associated with well-being factors. Compared to normal-weight/underweight peers, Previous presentations: Some findings were presented at the AcademyHealth Annual Research Meeting, June 2012. Published online July 15, 2015 overweight/obese medical students had worse overall health (b=−0.33; SE=0.03; p<0.001) and body esteem (b=−0.70; SE=0.02; p<0.001), and overweight/obese female students reported less social support (b=−0.12; SE=0.03; p<0.001) and more loneliness (b=0.22; SE=0.04; p<0.001). CONCLUSIONS: Perceived and internalized weight stigma may contribute to worse well-being among overweight/ obese medical students. KEY WORDS: Medical students; Stigmatization; Psychological stress; Obesity; Body weight. J Gen Intern Med 30(9):1251–8 DOI: 10.1007/s11606-015-3266-x © The Author(s) 2015. This article is published with open access at Springerlink.com succeed academically and professionally, medical stuT odents must withstand the stress of medical school, including learning new and complex material, meeting faculty expectations, interacting with patients, making new friends and colleagues, and assimilating the culture of medicine.1–3 Ability to cope with stress is important to health and professional development, as medical student stress is linked to burnout, substance use, mental health problems, suicidal thoughts, and poor academic performance.1,4–6 Stress also disproportionately affects female medical students, who may then be more vulnerable to these outcomes.5,7–9 Self-esteem, physical and emotional health, fatigue, sense of mastery, and social support all affect vulnerability to stress.10,11 Members of stigmatized groups, including overweight/obese individuals, may face additional stress.12–17 Experiences of weight-related stigma can have negative effects on self-esteem, health, and well-being. 12–14,17–23 Overweight/obese individuals may also be self-stigmatized, i.e., exhibit negative, self-deprecating attitudes about themselves, which may worsen their overall well-being.24–26 1251 1252 Phelan et al.: Adverse Effect of Weight Stigma on Medical Students’ Well-Being These additional stressors may challenge students’ ability to cope in the competitive medical school environment. Although little is known about the experience of these medical students, several studies have documented strong anti-fat attitudes among health care providers and trainees,27–31 and suggest that overweight/obese individuals are a common target of derogatory humor among medical students.32,33 The present study aimed to assess whether stigma or selfstigma is associated with factors that affect vulnerability to stress among overweight and obese medical students. We hypothesized that 1) these medical students, and female students in particular, have worse self-reported outcomes than normal-weight/underweight medical students on factors affecting vulnerability to stress; and that 2) among overweight/ obese students, experiencing more stigma/self-stigma is associated with worse outcomes. METHODS Sample This study used data from the Medical Student Cognitive Habits and Growth Evaluation Study (CHANGES), a study of first-year students at Liaison Committee on Medical Education (LCME)-accredited U.S. medical schools that was conducted in the fall of 2010. Our research study was approved by the institutional review board of the Mayo Clinic. We randomly selected 50 medical schools from the strata of public and private schools in six regions of the country, using sampleproportional-to-strata-size methodology. One sampled school with highly unique characteristics (military school) was excluded, leaving a sample of 49 schools. From these schools, we invited 5,82 (...truncated)