Layered stigma? Co-occurring depression and obesity in the public eye

doi:10.1016/j.jpsychores.2018.01.003

Journal of Psychosomatic Research

Volume 106, March 2018, Pages 29-33

https://doi.org/10.1016/j.jpsychores.2018.01.003 Get rights and content

Highlights

•
Obesity and depression are very prevalent and have a high co-morbidty.
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Research on the interaction of both conditions is lacking.
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Obesity and depression have been described as stigmatized conditions.
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The effect of both conditions occurring together on the magnitude of stigma is reported.
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Central conclusions for the role of stigma in treatment of both conditions are drawn.

Abstract

Objectives

Obesity and depression are common conditions in the general public and show a high level of co-morbidity. Both conditions are stigmatized, i.e., associated with negative attitudes and discrimination. Previous research shows that devalued conditions can overlap or combine to produce a layered stigma which is associated with more negative health outcomes than either single devalued condition alone. This study therefore set out to investigate the double stigma of obesity and depression.

Methods

A telephone-based representative study of the German population was conducted. Vignettes describing women with obesity, depression or both conditions were presented, followed by a set of items on semantic differentials based on previous stigma research of depression (depression stigma DS) and obesity (Fat Phobia Scale FPS). Personal experience with depression and obesity was assessed.

Results

All comparisons were significant in univariate ANOVA, showing negative attitudes measured by the FPS and the DS to be most pronounced in the double stigma condition. Multivariate analysis, controlling for age, gender, education and personal experience with the stigma condition (e.g. having obesity or depression), show that the double stigma obesity and depression is associated to more negative attitudes on the FPS (b = 0.163, p < 0.001) and the DS (b = 0.154, p = 0.002) compared to the single-stigma condition.

Conclusions

The magnitude of the layered stigma of obesity and depression may need to be considered in mental health settings when treating the depressed patient with obesity, but likewise in obesity care when treating the obese patient with depression.

Introduction

Obesity and depression are two of the most common civilization diseases. At any point in time, > 5 million people in Germany (8.1%) are affected by depressive symptoms based on the Patient Health Questionnaire (PHQ, cut-off 10) [1]. The 12-months prevalence of major depression was estimated at 11% based on a clinical interview [2]. Similarly, approximately one fifth of the population in Germany is diagnosed with obesity, defined by a body mass index (BMI) of over 30 kg/m² [3].

Both disorders share a high level of co-morbidity. Up to 23.2% of all women with obesity and 11.7% of all men with obesity show the presence of depressive symptoms [4], [5]. For Germany, this means that roughly 2 million people are affected by both disorders [6]. Two epidemiological reviews support these assumptions. In a meta-analysis of community-based studies, individuals with obesity have a 18% higher chance of co-morbid depression, compared to their normal-weight counterparts [7]. A later study included longitudinal studies and found a bi-directional relationship. Baseline obesity increased the risk for incident depression by 55% and depression at baseline resulted in a higher risk (58%) for obesity [8].

Both conditions are stigmatized, i.e., associated with negative attitudes and discrimination [9]. From what is known from research in other stigmatized conditions, such as HIV, being associated with more than one devalued condition can be considered a multiple or layered stigma [10], [11]. It is conceptualized as the situation where two independent stigmatized conditions are merged into a third, distinct reason for stigmatization. The term also underlines the impact that two or more stigmatizing conditions can have on an individual: With each stigmatizing condition, another layer of blame, marginalization, and reduced quality of life builds up [12]. In HIV stigma research, for example, this concept has helped to identify most vulnerable groups, such as homosexual men with HIV, in which this double stigma condition led to worse health care utilization and access to health care, higher rates of discrimination as well as lower quality of life [12].

Given the high level of comorbidity of obesity and depression, it seems reasonable people affected by both conditions face greater stigma and worse health consequences. The existence of this particular double stigma has been proposed for obesity and other serious mental illnesses [13], but has not been investigated in general nor for depression in particular. One finding, pointing in this direction, is the fact that depression among people with obesity is more common in settings where obesity is less prevalent, and where thus obesity constitutes a greater deviation of body norms and is stigmatized as such [14]. Women inparticular are vulnerable to weight stigma and are often the focus of devaluation because of their weight [15], [16]. It has been documented in the past, that obesity and weight stigma can be a barrier to access to health care and in particular to preventive services and cancer screenings [17]. For example, a meta-analysis summarizing six representative studies from the United States on mammography showed that women with obesity were less likely to utilize this preventive service [18]. Reasons for delays and avoidance of preventive care include stigmatizing experiences such as negative comments and discriminatory facilities, such as not having equipment for women with obesity [19]. Women also carry a higher risk for depression [1]. Devaluation of patients with depression can also be a potential barrier to help seeking treatment [21]. Layered stigma of obesity and depression may thus result in even lower health utilization than each condition alone. The experiences of people then carrying a double stigma, and the impact of this double stigma, however, remain unknown. In a first step, the public stigma needs to be described to provide a basis for further investigations in patients affected by obesity and depression. The aim of this study, therefore, is to investigate the attitudes of the general public towards women depression and obesity.

Section snippets

Study design

This study is a population based study from Germany. An institute for research and market research was commissioned to conduct a telephone based survey of people dwelling in the community older than 18. Households were called and participants within a household were randomly selected for participation. A random digital dialing approach was used to include households not registered in the phone book and mobile numbers. The interview schedule, including a vignette-based approach, was developed by

Results

Differences across the two different aggregated scales for stigmatizing attitudes (FPS and DS) after the three different vignettes are shown in Table 4. On both scales, a person with depression and obesity was rated least favorably. With regard to the FPS, a person with simple depression was rated more favorably than a person with simple obesity, while both persons with obesity and with depression were rated similarly with regard to depression stigma. Mean scores on the FPS ranged from M = 3.23

Discussion

This study set out to investigate the presence of double stigma in the two stigmatized illnesses obesity and depression. For obesity and depression, it was shown that the co-occurrence of obesity and depression was associated with more negative stigmatizing attitudes as measured on an obesity specific stigma scale.

Our results document the overlap of stereotypes between different conditions in the first place. Depending on the measure used to assess stigma across different conditions, results

Conclusions

This study shows that obesity and depression are devalued conditions that can combine to a layered stigma, which may affect health outcomes. Women with obesity and depression are devalued more compared to women with only one condition. Future research is needed to clarify effects of this devaluation on the individual but also on a societal level. Individuals with a greater magnitude of internalized stigma, rooted in the public stigma documented in the study, may have greater barriers to health

Acknowledgment

This work was supported by the Federal Ministry of Education and Research (BMBF), Germany, FKZ: 01EO1501.

Conflict of interest

None.

Ethical standards

The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008.

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Layered stigma? Co-occurring depression and obesity in the public eye

Highlights

Abstract

Objectives

Methods

Results

Conclusions

Introduction

Section snippets

Study design

Results

Discussion

Conclusions

Acknowledgment

Conflict of interest

Ethical standards

Soc. Sci. Med. (1982)

Am. J. Prev. Med.

Psychiatry Res.

J. Affect. Disord.

J. Affect. Disord.

Prävalenz von depressiver Symptomatik und diagnostizierter Depression bei Erwachsenen in Deutschland: Ergebnisse der Studie zur Gesundheit Erwachsener in Deutschland (DEGS1)

Bundesgesundheitsbl. Gesundheitsforsch. Gesundheitsschutz

Depressive Erkrankungen

Overweight and obesity in Germany. Results of the German health interview and examination survey for adults (DEGS1)

Bundesgesundheitsbl. Gesundheitsforsch. Gesundheitsschutz

Depressive mood and obesity in US adults: comparison and moderation by sex, age, and race

Int. J. obes. (2005).

Bevölkerung - Zahl der Einwohner in Deutschland nach Altersgruppen am 31

Depression and obesity: a meta-analysis of community-based studies

Psychiatry Res.

Overweight, obesity, and depression: a systematic review and meta-analysis of longitudinal studies

Arch. Gen. Psychiatry

Grundbegriffe der Soziologie

Layered stigma among health-care and social service providers toward key affected populations in Jamaica and The Bahamas

AIDS Care

A theoretical model of multiple stigma: ostracized for being an inmate with intellectual disabilities

J. Scand. Stud. Criminol. Crime Prev.

Stigma in the HIV/AIDS epidemic: a review of the literature and recommendations for the way forward

AIDS (London, England)

The double stigma of obesity and serious mental illnesses: promoting health and recovery

Psychiatr. Rehabil. J.