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Weight Stigma by Association Among Parents of Children With Obesity: A Randomized Trial

Open AccessPublished:October 02, 2021DOI:https://doi.org/10.1016/j.acap.2021.09.019

      Abstract

      Objective

      To experimentally test weight stigma and weight stigma by association in a parent-child relationship using a large, community-based sample.

      Methods

      We conducted a randomized experiment on Amazon Mechanical Turk using an online survey. Participants were randomly assigned to view a picture of a parent-child dyad, for which the parent and child's gender (male vs. female) and weight status (with obesity vs. without obesity) were manipulated. Participants read identical parenting descriptions that adhered to the American Academy of Pediatrics’ parenting recommendations, then rated the parent's perceived effectiveness, helpfulness, and level of caring using a parenting questionnaire based on Barnhart et al (2013).

      Results

      Participants (N = 1862; Mage = 36.8 [11.2] years) rated parents of children with obesity as less effective compared to parents of children without obesity (P = .010) and parents with obesity as less effective compared to parents without obesity (P = .033). Participants also rated parents with obesity as less helpful compared to parents without obesity (P = .021). No differences emerged in perceived caring. Parenting evaluations did not differ across daughters versus sons or mothers versus fathers.

      Conclusions

      Parents of children with obesity may experience weight stigma by association, which could have direct consequences for the parents, the children, and the parent-child relationship.

      Keywords

      What's New
      In a randomized experiment in which weight status of parent-child dyads were manipulated, parents of children with obesity were judged more negatively despite being described in the same manner. This “weight stigma by association” could adversely affect the parent-child relationship.
      Weight stigma, defined as the social devaluation of individuals with higher weight status through weight-based prejudice, negative stereotyping, and discrimination,
      • Tomiyama AJ
      Weight stigma is stressful. A review of evidence for the Cyclic Obesity/Weight-Based Stigma model.
      is highly prevalent.
      • Puhl RM
      • Andreyeva T
      • Brownell KD
      Perceptions of weight discrimination: prevalence and comparison to race and gender discrimination in America.
      Children and adolescents with obesity are victim to weight-based teasing, bullying, and social rejection, and those at upper weight percentiles are more likely to endure severe and frequent forms of weight stigma.

      Puhl RM, Latner JD. Stigma, obesity, and the health of the nation's children. 2007;133:557-580. https://doi.org/10.1037/0033-2909.133.4.557

      As adults, individuals with obesity continue to experience mistreatment in the form of weight-based discrimination across several critical life domains including healthcare, education, and employment.
      • Puhl RM
      • Heuer CA
      The stigma of obesity: a review and update.
      The cumulative effect of experiencing weight stigma is likely to be harmful. Individuals who are stigmatized for their weight report poorer health behaviors such as greater maladaptive eating, sleep disturbance, and alcohol use.
      • Lee KM
      • Hunger JM
      • Tomiyama AJ
      Weight stigma and health behaviors: evidence from the Eating in America Study.
      Furthermore, there is compelling evidence that weight stigma is physiologically stressful and may contribute to increased risk of allostatic load, which predicts early mortality.
      • Tomiyama AJ
      Weight stigma is stressful. A review of evidence for the Cyclic Obesity/Weight-Based Stigma model.
      ,
      • Vadiveloo M
      • Mattei J
      Perceived weight discrimination and 10-year risk of allostatic load among US adults.
      Weight stigma has also been linked to greater risk of obesity,
      • Ma L
      • Chu M
      • Li Y
      • et al.
      Bidirectional relationships between weight stigma and pediatric obesity: a systematic review and meta-analysis.
      psychopathology (eg, depression),
      • Hatzenbuehler ML
      • Keyes KM
      • Hasin DS
      Associations between perceived weight discrimination and the prevalence of psychiatric disorders in the general population.
      and mortality,
      • Sutin AR
      • Stephan Y
      • Terracciano A.
      Weight discrimination and risk of mortality.
      independent of body mass index (BMI). Considering the significant health risks associated with weight stigma, it is vitally important to investigate how weight stigma affects families, specifically the parent-child dyad.
      Most of the current research on weight stigma considers adults and children separately, yet growing evidence suggests that parents of children with obesity may be the target of weight stigma by association—a phenomenon in which a person (here, the parent) is stigmatized because of another person's stigmatized condition (here, the child with obesity).
      • Goffman E.
      Stigma and social identity.
      Some studies suggest that mothers of children with higher weight feel shamed by family members who criticize their parenting behaviors or feel unheard by physicians who question their feeding practices during routine visits.
      • Gorlick JC
      • Gorman CV
      • Weeks HM
      • et al.
      I Feel like Less of a Mom”: experiences of weight stigma by association among mothers of children with overweight and obesity.
      Although stigma by association has been examined among caregivers of other stigmatized groups,
      • Kinnear S
      • Link B
      • Ballan MS
      • et al.
      Understanding the experience of stigma for parents of children with autism spectrum disorder and the role stigma plays in families’ lives.
      ,
      • Baudino MN
      • Perez MN
      • Roberts CM
      • et al.
      Stigma by association: parent stigma and youth adjustment in inflammatory bowel disease.
      there is less research on weight stigma by association and no experimental studies, to our knowledge, on weight stigma by association in parent-child dyads.
      One reason that parents of children with higher weight may experience weight stigma by association is that the perceived onus of pediatric obesity is on the parent, rather than the child.
      • Lusk JL
      • Ellison B
      Who is to blame for the rise in obesity?.
      ,
      • Golan M
      Parents as agents of change in childhood obesity—from research to practice.
      Severe childhood obesity is sometimes identified as evidence of parental neglect,
      • Todd V
      • Allen DB
      • Carrel AL
      • et al.
      Childhood obesity and medical neglect.
      and qualitative work similarly attributes obesity in children to “bad parenting” (even when respondents themselves and their own children have obesity).
      • Kalinowski A
      • Krause K
      • Berdejo C
      • et al.
      Beliefs about the role of parenting in feeding and childhood obesity among mothers of lower socioeconomic status.
      These attributions for weight status may stem from research linking general parenting and children's weight-related outcomes. For example, children raised by mothers with authoritarian parenting styles (ie, high expectations for self-control, low in sensitivity) were significantly more likely to be overweight in first grade compared to those raised in authoritative households (ie, high expectations for self-control, high in sensitivity).
      • Rhee KE
      • Lumeng JC
      • Appugliese DP
      • et al.
      Parenting styles and overweight status in first grade.
      Given the parent's role in the prevention and treatment of pediatric obesity,
      • Nobile C
      • Drotar D.
      Research on the quality of parent-provider communication in pediatric care: implications and recommendations.
      it is important to examine how social factors like weight stigma and stigma by association may affect perceptions of parenting. However, randomized experiments on weight stigma and stigma by association among parents of children with obesity are noticeably absent. While some parents fear being stigmatized,
      • Gorlick JC
      • Gorman CV
      • Weeks HM
      • et al.
      I Feel like Less of a Mom”: experiences of weight stigma by association among mothers of children with overweight and obesity.
      it is unknown whether the general public judges parents of children with obesity more negatively (ie, less effective, helpful, or caring) than those of children without obesity. Moreover, the existing qualitative research on weight stigma by association in the parent-child relationship has been limited in its generalizability due to small sample sizes (N < 50)
      • Gorlick JC
      • Gorman CV
      • Weeks HM
      • et al.
      I Feel like Less of a Mom”: experiences of weight stigma by association among mothers of children with overweight and obesity.
      and unique samples (ie, caregivers with children in weight loss programs
      • Zenlea IS
      • Thompson B
      • Fierheller D
      • et al.
      Walking in the shoes of caregivers of children with obesity: supporting caregivers in paediatric weight management.
      or parents of children with obesity related to medical conditions).
      • Hamlington B
      • Ivey LE
      • Brenna E
      • et al.
      Characterization of courtesy stigma perceived by parents of overweight children with Bardet-Biedl syndrome.
      Therefore, to fill these critical gaps in the literature, we conducted a randomized experiment testing weight stigma and stigma by association in a parent-child relationship using a large, community-based sample. Weight status (with obesity vs. without obesity) and gender (male vs. female) were manipulated within each parent-child pairing.
      We tested the a priori hypotheses that all 3 outcome variables for general parenting (effectiveness, helpfulness, and caring) would be rated lower in: 1) Parents of children with obesity versus parents of children without obesity, 2) Parents with obesity versus parents without obesity, and 3) Parents of daughters with obesity versus parents of sons with obesity.
      Given the gender bias against women, in the context of weight stigma, we tested 2 additional hypotheses: 1) Mothers of children with obesity versus fathers of children with obesity, and 2) Mothers of daughters with obesity versus fathers of daughters with obesity. We predicted that weight stigma by association would likely be more severe for mothers and the mother-daughter dyad as women are more likely to be stigmatized for their weight.
      • Puhl RM
      • Andreyeva T
      • Brownell KD
      Perceptions of weight discrimination: prevalence and comparison to race and gender discrimination in America.
      Maternal obesity is also a stronger risk factor for offspring obesity than paternal obesity,
      • Linabery AM
      • Nahhas RW
      • Johnson W
      • et al.
      Stronger influence of maternal than paternal obesity on infant and early childhood body mass index: the Fels Longitudinal Study.
      and mothers are more often viewed as responsible for their children's weight and eating behaviors.
      • Quirke L.
      “Fat-proof your child”: parenting advice and “child obesity”.

      Methods

      Overall Design

      In order to infer causality, we conducted a 2 (parent with obesity vs. without obesity) x 2 (child with obesity vs without obesity) x 2 (daughter vs son) x 2 (mother vs father) between-subjects experiment. Participants completed demographic questions, viewed a parent-child dyad image and read a general parenting vignette, then completed a 3-item questionnaire rating the parent (ie, “To what extent do you perceive the parenting approach to be helpful/effective/caring?”; available from the author on request). Participants indicated their responses on a 5-point Likert scale (1 = Not at all to 5 = Very). The vignette was constructed based on parenting recommendations for 7-8 year olds set forth by the American Academy of Pediatrics (available from the author on request). This specific age range was chosen to avoid potential confounding related to early onset puberty for higher weight children
      • Lee JM
      • Appugliese D
      • Kaciroti N
      • et al.
      Weight status in young girls and the onset of puberty.
      or difficulty recognizing childhood overweight or obesity among children under the age of 6.
      • Eckstein KC
      • Mikhail LM
      • Ariza AJ
      • et al.
      Parents’ perceptions of their child's weight and health.
      Participants (N = 1,973, age ≥ 18 years) in the United States were recruited using Amazon MTurk, which provides reliable, higher-quality data
      • Hauser DJ
      • Schwarz N.
      Attentive Turkers: MTurk participants perform better on online attention checks than do subject pool participants.
      from a more diverse and generalizable sample than typical community samples. We used G*Power software to conduct a power analysis. For highest-order interaction power of .80 and an effect size of d = 0.20, we calculated a sample size of 1894 at an alpha = .05. The study was advertised as the “Parent-Child Behavior Survey.” Standard exclusion criteria were duplicate IP addresses, response times < 60 s or > 3600 s (the allotted time to complete the survey), or failure to complete the parenting questionnaire. After applying exclusion criteria, 111 responses were dropped, comprising a final sample size of 1862 participants. Participants provided online written informed consent and were compensated $0.75; a standard compensation amount on MTurk. The University of California Los Angeles Institutional Review Board approved the study.
      For the images associated with the vignettes, participants were randomly assigned to one of 16 conditions (Table 3 and Figure). Each condition featured an image of a parent-child dyad, in which weight status (with obesity vs without obesity) and gender (male vs female) were manipulated. The images were generated from 2 Shutterstock stock photo images of a white parent and child shown together. We selected a white parent-child dyad as the effect of obesity on stigma by association is likely to differ by race or ethnicity and will require a dedicated study. We used random assignment in the experiment to mitigate any potential bias among raters.
      Based on previous methodology,
      • Benton C
      • Karazsia BT.
      The effect of thin and muscular images on women's body satisfaction.
      we first piloted (N = 37) 4 images for each parent and child target on MTurk to identify male and female images that were matched on levels of happiness, friendliness, and estimated age. This ensured that if a target parent received more positive parenting ratings, it would not be because they were perceived as happier, friendlier, or older (available from the author on request). With the selected images, we then digitally manipulated weight of the targets using Adobe Photoshop CC (Version 20.0) software (Adobe, San Jose, Calif). As a manipulation check, at the end of the study, participants rated the BMI of the experimental stimuli using standard figure rating scales. For adult stimuli, the scale featured 8 bodies with BMIs ranging from 14 to 46. For child stimuli, the scale featured 7 bodies of girls and boys with BMIs spanning the 3rd to 97th percentiles for a 7–12-year-old child. Participants accurately perceived that targets with obesity were heavier than the targets without obesity for both parents and children (P < .001 for all comparisons). Experimental stimuli for the 16 conditions were provided (available from the author on request) (see Supplementary material).
      Figure
      FigureFlow diagram of the phases of the randomized trial.

      Analytic Plan

      Given the large number of potential interactions in this 2 × 2 × 2 × 2 design, we only tested the 5 a priori hypotheses to avoid false positives. SPSS software (v. 26) was used to complete analyses. Each dummy-coded independent samples t-test corresponded to one of the 5 hypotheses. For example, to test the hypothesis that mothers of daughters with obesity are rated lower on general parenting than fathers of daughters with obesity, we dummy-coded mothers of daughters with obesity as “0” and fathers of daughters with obesity as “1”, then used this variable as the grouping factor for the t-test.

      Results

      The sample of participants was 56.4% Female with a mean (standard deviation) age of 36.8 (11.2) years. Participants were predominantly white (71.7%) and 4-year college graduates (45.6%) (Table 1). None of the conditions differed on demographic factors (all Ps > .05), indicating successful randomization. The mean (standard deviation SD) parenting ratings for each of the 3 parenting items per condition are shown in Table 2.
      Table 1Characteristics of Survey Respondents (N = 1862)
      CharacteristicN(%)
      Gender
      Eight participants did not report gender.
        Women105056.4
        Men79842.9
        Nonbinary/other60.4
      Race/ethnicity
        White133571.7
        Black, African American1769.5
        Native American, Eskimo, Aleut251.3
        Hispanic, Latino/a1467.8
        Asian, Asian American1427.6
        Native Hawaiian or Pacific Islander70.4
        Biracial/Multiracial231.2
        Other80.4
      Education
        No degree181.0
        High school diploma or GED36019.3
        Associate degree26814.4
        Bachelor's degree84945.6
        Master's degree30616.4
        Doctorate or professional degree341.8
        Other251.3
      Income
        Less than $20,0001719.2
        $20,000–$29,9991467.8
        $30,000–$39,9991387.4
        $40,000–$49,99924313.1
        $50,000–$59,99927714.9
        $60,000–$69,9991829.8
        $70,000–$79,9991417.6
        $80,000–$89,9991216.5
        $90,000–$99,9991337.1
        $100,000–$149,99922512.1
        More than $150,000834.5
      low asterisk Eight participants did not report gender.
      Table 2General Parenting Mean Ratings
      HypothesesEffective

      M (SD)
      PHelpful

      M (SD)
      PCaring

      M (SD)
      P
      1. Parents of children with obesity are rated lower in general parenting than parents of children without obesity.010.114.054
        Parents of children with obesity4.15 (0.85)4.23 (0.86)4.52 (0.77)
        Parents of children without obesity4.24 (0.77)4.29 (0.83)4.59 (0.71)
      2. Parents with obesity are rated lower in general parenting than parents without obesity.033.021.862
        Parents with obesity4.16 (0.82)4.22 (0.88)4.55 (0.74)
        Parents without obesity4.24 (0.80)4.31 (0.81)4.56 (0.74)
      3. Parents of daughters with obesity are rated lower in general parenting than parents of sons with obesity.392.578.954
        Parents of daughters with obesity4.17 (0.81)4.25 (0.88)4.52 (0.76)
        Parents of sons with obesity4.12 (0.88)4.22 (0.85)4.52 (0.78)
      4. Mothers of children with obesity are rated lower in general parenting than fathers of children with obesity.603.747.889
        Mothers of children with obesity4.13 (0.85)4.22 (0.85)4.52 (0.80)
        Fathers of children with obesity4.16 (0.85)4.24 (0.88)4.52 (0.74)
      5. Mothers of daughters with obesity are rated lower in general parenting than fathers of daughters with obesity.173.104.124
        Mothers of daughters with obesity4.12 (0.79)4.18 (0.88)4.46 (0.80)
        Fathers of daughters with obesity4.22 (0.83)4.31 (0.88)4.57 (0.71)
      M indicates mean; SD, standard deviation.
      Participants responded to the prompt, “To what extent do you perceive the parenting approach to be effective/helpful/caring?” and rated the characteristic on a 5-point Likert scale (1 = Not at all, 5 = Very). Bolded items indicate P-values < .05.
      Table 3Study Conditions
      ConditionsN
      1. Mother with obesity, daughter with obesity115
      2. Mother with obesity, daughter without obesity117
      3. Mother without obesity, daughter with obesity113
      4. Mother without obesity, daughter without obesity119
      5. Mother with obesity, son with obesity118
      6. Mother with obesity, son without obesity116
      7. Mother without obesity, son with obesity110
      8. Mother without obesity, son without obesity119
      9. Father with obesity, daughter with obesity115
      10. Father with obesity, daughter without obesity118
      11. Father without obesity, daughter with obesity115
      12. Father without obesity, daughter without obesity121
      13. Father with obesity, son with obesity121
      14. Father with obesity, son without obesity116
      15. Father without obesity, son with obesity116
      16. Father without obesity, son without obesity113
      Our first hypothesis, that parents of children with obesity are rated more negatively in general parenting than parents of children without obesity, was partially supported. Participants rated parents of children with obesity as less effective (4.15 [0.85]) compared to parents of children without obesity (4.24 [0.77]; P = .010). There were no significant differences in perceived helpfulness or caring between parents of children with obesity and parents of children without obesity (Ps > .05)
      Our second hypothesis, that parents with obesity are rated more negatively in general parenting than parents without obesity was mostly supported. Parents with obesity (4.16 [0.82]) were rated as less effective compared to parents without obesity (4.24 [0.80]; P = .033). Parents with obesity were also rated as less helpful (4.22 [0.88]) compared to those without obesity (4.31 [0.81]; P = .021). There was no significant difference in perceived caring between parents with obesity and parents without obesity (P > .05).
      Our third hypothesis, that parents of daughters with obesity are rated more negatively in general parenting than parents of sons with obesity was not supported. There were no significant differences in perceived effectiveness, helpfulness, or caring between parents of daughters with obesity and parents of sons with obesity (Ps > .05).
      Our fourth hypothesis, that mothers of children with obesity are rated more negatively in general parenting than fathers of children with obesity was not supported. There were no significant differences in perceived effectiveness, helpfulness, or caring between mothers of children with obesity and fathers of children with obesity (Ps > .05).
      Lastly, our fifth hypothesis, that mothers of daughters with obesity are rated more negatively in general parenting than fathers of daughters with obesity, was not supported. There were no significant differences in perceived effectiveness, helpfulness, or caring between mothers of daughters with obesity and fathers of daughters with obesity (Ps > .05).
      We conducted exploratory analyses to test whether the significant effects observed were modulated by gender, income, race/ethnicity, caregiver status (whether respondents were parents/caregivers themselves), and respondent BMI. We did not find any evidence of modulation, other than for race and child weight status for parent effectiveness: compared to Asian respondents, white respondents were significantly more likely to rate parents of children with obesity as lower on effectiveness (P = .012). Given the exploratory nature of these analyses, this single significant result should be interpreted with caution and warrants replication.

      Discussion

      In line with qualitative work on weight stigma by association,
      • Zenlea IS
      • Thompson B
      • Fierheller D
      • et al.
      Walking in the shoes of caregivers of children with obesity: supporting caregivers in paediatric weight management.
      ,
      • Hamlington B
      • Ivey LE
      • Brenna E
      • et al.
      Characterization of courtesy stigma perceived by parents of overweight children with Bardet-Biedl syndrome.
      ,
      • Davis JL
      • Goar C
      • Manago B
      • et al.
      Distribution and disavowal: managing the parental stigma of Children's weight and weight loss.
      parents of children with obesity were rated as less effective compared to parents of children without obesity, regardless of the parents’ weight. There was also an effect of weight stigma wherein parents with obesity were also rated as less effective and helpful than parents without obesity. These modest differences emerged despite showing participants identical vignettes of the parent-child dyad, which described parenting that adhered to American Academy of Pediatrics recommendations. These ratings did not differ based on the gender of the experimental stimuli, whether comparing mothers to fathers or daughters to sons.
      Our results suggest that all else being equal, parents of children with obesity are evaluated less positively because of their child's weight, even when their parenting practices align with professional pediatric recommendations. It may be that a child's weight status is more salient than positive parenting behaviors, particularly among those who believe that parents are responsible for their child's weight.
      • Barry CL
      • Gollust SE
      • Niederdeppe J.
      Are Americans ready to solve the weight of the nation?.
      In response, stigmatized parents may internalize the negative parenting evaluations and subject themselves to further self-blame for their children's weight.
      • Jackson D
      • Wilkes L
      • McDonald G.
      ‘If I was in my daughter's body I'd be feeling devastated’: women's experiences of mothering an overweight or obese child.
      They may also develop negative attitudes towards parenting that indirectly affect their child, as studies related to other chronic health conditions have shown. For example, one study on pediatric inflammatory bowel disease found that parents who experienced associative stigma for their child's chronic inflammatory bowel disease reported greater disruptions to their personal lives because of their child's illness, which in turn was associated with greater depressive symptomology in their child.
      • Baudino MN
      • Perez MN
      • Roberts CM
      • et al.
      Stigma by association: parent stigma and youth adjustment in inflammatory bowel disease.
      Parents who experience weight stigma themselves may alter their parenting behaviors as well. One study found that parents who were stigmatized for their own weight reported greater use of restrictive feeding practices out of concern for their child's weight.
      • Gold JM
      • vander Weg MW
      Investigating the relationship between parental weight stigma and feeding practices.
      Yet, there is strong evidence that maternal restrictive feeding leads to overeating in children.
      • Birch LL
      • Fisher JO
      • Davison KK
      Learning to overeat: maternal use of restrictive feeding practices promotes girls’ eating in the absence of hunger 1-3.
      Parents who experience weight stigma by association may also respond by stigmatizing their own children, potentially increasing their children's vulnerability to weight gain. One study found that the odds of having an obese BMI almost ten years later were 62% greater when female youth were called “too fat” by family members, independent of their baseline BMIs.
      • Hunger JM
      • Tomiyama AJ
      Weight labeling and disordered eating among adolescent girls: Longitudinal evidence from the national heart, lung and blood institute growth and health study.
      One potential mechanism for this association is weight bias internalization, in which an individual self-stigmatizes (eg, endorses the negative stereotypes associated with the stigmatized social identity), leading to a devalued sense of self due to their weight. Higher weight bias internalization has been associated with greater severity of obesity and diminished motivation to act in health promoting ways.
      • Pearl RL
      • Puhl RM
      Weight bias internalization and health: a systematic review.
      More research is needed to identify the potential ways that weight stigma and stigma by association may harm the parent-child relationship and undermine good parenting intentions.
      Weight stigma by association may be most consequential in healthcare.
      • Phelan S.M.
      • Burgess D.J.
      • Yeazel M.W.
      • et al.
      Impact of weight bias and stigma on quality of care and outcomes for patients with obesity.
      ,
      • Puhl RM
      • Lessard LM
      • Himmelstein MS
      • et al.
      The roles of experienced and internalized weight stigma in healthcare experiences: perspectives of adults engaged in weight management across six countries.
      Strong implicit and explicit anti-fat and weight bias have been reported in large samples of healthcare providers
      • Sabin JA
      • Marini M
      • Nosek BA
      Implicit and explicit anti-fat bias among a large sample of medical doctors by BMI, race/ethnicity, and gender.
      and medical students,
      • Phelan SM
      • Dovidio JF
      • Puhl RM
      • et al.
      Implicit and explicit weight bias in a national sample of 4,732 medical students: the medical student CHANGES study.
      and emerging evidence suggests that weight bias occurs in pediatric settings as well.
      • Garcia JT
      • Amankwah EK
      • Hernandez RG
      Assessment of weight bias among pediatric nurses and clinical support staff toward obese patients and their caregivers.
      ,
      • Halvorson EE
      • Curley T
      • Wright M
      • et al.
      Weight bias in pediatric inpatient care.
      Research shows that individuals with higher weight receive less health education compared to those with normal weight
      • Bertakis KD
      • Azari R
      The impact of obesity on primary care visits.
      and are subject to stigmatizing language (eg, “obese”; “fat”).
      • Puhl RM
      What words should we use to talk about weight? A systematic review of quantitative and qualitative studies examining preferences for weight-related terminology.
      Using stigmatizing weight-related terminology with patients contributes to an obesity discourse that continues to pathologize higher weight, promote weight-centered approaches to improving health, and over-emphasize individual responsibility
      • Hunger JM
      • Smith JP
      • Tomiyama AJ
      An evidence-based rationale for adopting weight-inclusive health policy.
      despite strong evidence for multi-level contributors to pediatric obesity (eg, school environments, food policy).
      • Barry CL
      • Gollust SE
      • Niederdeppe J.
      Are Americans ready to solve the weight of the nation?.
      Furthermore, such language may interfere with effective parent-provider communication, which is a key contributor to optimal outcomes in pediatrics.
      • Nobile C
      • Drotar D.
      Research on the quality of parent-provider communication in pediatric care: implications and recommendations.
      In particular, effective parent-provider communication characterized by positive affect and empathy is associated with higher parent satisfaction with care and communication ratings.
      • Nobile C
      • Drotar D.
      Research on the quality of parent-provider communication in pediatric care: implications and recommendations.
      Thus, research is urgently needed to investigate whether healthcare providers may also view parents of children with obesity more negatively than parents of children without obesity, even when presented with identical evidence of positive parenting behaviors. One study found that more than 80% of pediatricians perceived a lack of parental involvement as a major barrier in the treatment of pediatric obesity.
      • Story MT
      • Neumark-Stzainer DR
      • Sherwood NE
      • et al.
      Management of child and adolescent obesity: attitudes, barriers, skills, and training needs among health care professionals.
      Weight stigma by association could potentially play some part in this perception. If parent-child dyads with obesity are experiencing weight stigma, the pediatrician has several roles: 1) monitor for this bias in their own interactions with these dyads; 2) consider that information about the child from outside agencies (ie, schools, therapists), could be tainted by bias, and therefore should be interpreted in this context; 3) consider how bias could impact the parent-child relationship and the parent's treatment of the child; 4) in some cases, acknowledge how weight bias may be impacting the family.
      The present study has several strengths. This is the first randomized experiment to test weight stigma by association in a parent-child dyad using a large community sample. As such, the study's internal validity was enhanced by using random assignment, which places participants into study groups using randomization, thus balancing all potential variables and confounds across groups. Previous studies have used sample sizes under 50 participants or have relied on qualitative research methods such as semi-structured interviews to gather data. Another strength of this study was the use of digitally manipulated images, which were standardized on all other physical characteristics besides weight status. This allows us to attribute more negative parenting ratings to differences in weight status, rather than other physical features. Lastly, we used the same vignette of the parent-child dyad in all experimental conditions, which was crafted using the American Academy of Pediatrics parenting recommendations. Therefore, our experimental stimuli represented positive parenting practices.
      Some limitations of the study should be noted. First, parenting ratings were relatively high (average scores within the 4–5 range, on a 5-point rating scale), in that participants rated all target parents as effective, helpful, and caring. It may be that obesity-specific parenting, such as feeding behavior or children's screen-time monitoring, would invite greater criticism. Nonetheless, the fact that parents were differentially rated given an identical vignette designed to portray positive parenting is notable. Although the obtained effect size was small, the cumulative effect of experiencing weight stigma by association may be detrimental given the high frequency of parent-child social interactions in daily life. Next, the stimuli featured only white parent-child dyads, making this a conservative test of weight stigma by association.
      Overall, the present randomized experimental study provides causal (rather than merely associative) evidence that weight stigma by association indeed occurs. Future work should examine how families of different racial/ethnic backgrounds may experience weight stigma by association given that obesity disproportionately affects communities of color.
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      • Ogden CL
      Prevalence of overweight, obesity, and severe obesity among children and adolescents aged 2–19 years: United States, 1963–1965 through 2017–2018.
      Understanding whether varying degrees of higher weight status in children may impact parenting perceptions is also warranted. Though a nascent area of research, weight stigma by association may have potential implications for parenting and effective pediatric obesity care.

      Acknowledgment

      Financial statement: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

      Appendix. Supplementary Data

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