UCSF
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Title
Associations of weight stigma with cortisol and oxidative stress independent of adiposity.
Permalink
https://escholarship.org/uc/item/3t59n4bf
Journal
Health psychology : official journal of the Division of Health Psychology, American
Psychological Association, 33(8)
ISSN
0278-6133
Authors
Tomiyama, A Janet
Epel, Elissa S
McClatchey, Trissa M
et al.
Publication Date
2014-08-01
DOI
10.1037/hea0000107
Peer reviewed
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University of California
BRIEF REPORT
Associations of Weight Stigma With Cortisol and Oxidative Stress
Independent of Adiposity
A. Janet Tomiyama
University of California, Los Angeles
Elissa S. Epel
University of California, San Francisco
Trissa M. McClatchey
Baylor College of Medicine
Gina Poelke and Margaret E. Kemeny
University of California, San Francisco
Shannon K. McCoy
University of Maine
Jennifer Daubenmier
University of California, San Francisco
Objective: Weight discrimination is associated with increased risk of obesity. The mechanism of this
relationship is unknown, but being overweight is a highly stigmatized condition and may be a source of
chronic stress that contributes to the development and pathophysiology of obesity. The objective of this study
was to test whether weight stigma is associated with physiological risk factors linked to stress and obesity,
including hypercortisolism and oxidative stress, independent of adiposity. Method: We examined the fre-
quency of experiencing situations involving weight stigma and consciousness of weight stigma in relation to
hypothalamic⫺pituitary⫺adrenal axis activity and oxidative stress (F
2
-isoprostanes) in 45 healthy overweight
to obese women. Results: Independent of abdominal fat, weight stigma was significantly related to measures
of cortisol (including salivary measures of cortisol awakening response and serum morning levels) as well as
higher levels of oxidative stress. Perceived stress mediated the relationship between weight stigma conscious-
ness and the cortisol awakening response. Conclusion: These preliminary findings show that weight stigma
is associated with greater biochemical stress, independent of level of adiposity. It is possible that weight stigma
may contribute to poor health underlying some forms of obesity.
Keywords: social stigma, weight stigma, oxidative stress, cortisol, stress, obesity, cortisol awakening
response
Supplemental materials: http://dx.doi.org/10.1037/hea0000107.supp
The rise in obesity prevalence in the United States has elicited
a heated dialogue across government, medical, and academic in-
stitutions, centering on the negative consequences of an obese
society, such as chronic health conditions, shorter life expectancy
(Fontaine, Redden, Wang, Westfall, & Allison, 2003), and eco-
nomic costs (Hammond & Levine, 2010). The framing of obesity
A. Janet Tomiyama, Department of Psychology, University of Cali-
fornia, Los Angeles; Elissa S. Epel, Department of Psychiatry, Univer-
sity of California, San Francisco; Trissa M. McClatchey, Baylor Col-
lege of Medicine; Gina Poelke and Margaret E. Kemeny, Department of
Psychiatry, University of California, San Francisco; Shannon K. Mc-
Coy, Department of Psychology, University of Maine; and Jennifer
Daubenmier, Osher Center for Integrative Medicine, University of
California, San Francisco.
Supported by the Robert Wood Johnson Foundation Health and
Society Scholars program; Mount Zion Health Fund; The William
Bowes, Jr., Fund; the Robert Deidrick Fund; National Center for
Complementary and Alternative Medicine, National Institutes of Health
(Grant K01AT004199 awarded to Jennifer Daubenmier); and the Na-
tional Institutes of Health/National Center for Research Resources
University of California, San Francisco, Clinical and Translational
Science Institute (Grant ULI RR024131). The content is solely the
responsibility of the authors and does not necessarily represent the
official views of the National Center for Complementary and Alterna-
tive Medicine or the National Institutes of Health. We thank Nicole
Maninger, PhD, University of California, Davis; and Margaret Kuwata,
BA, and Kinnari Jhaveri, BA, at the University of California, San
Francisco, for collecting the data. We are grateful for assistance in
manuscript preparation from Angela C. Incollingo Belsky and Jolene
Nguyen-Cuu.
Correspondence concerning this article should be addressed to A. Janet
Tomiyama, University of California, Los Angeles, 1285 Franz Hall, 502
Portola Plaza, Los Angeles, CA 90095-1563. E-mail: tomiyama@psych
.ucla.edu and to Jennifer Daubenmier, University of California, San Fran-
cisco, P.O. Box 1726, San Francisco, CA 94143. E-mail: Jennifer
.daubenmier@ucsf.edu
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Health Psychology © 2014 American Psychological Association
2014, Vol. 33, No. 8, 862–867 0278-6133/14/$12.00 http://dx.doi.org/10.1037/hea0000107
862
as a health threat and social burden creates fertile ground for
stigma to develop. Discrimination rates based on weight are sim-
ilar to those based on race and gender, and higher in some
instances, such as those involving interpersonal mistreatment (Puhl
& Heuer, 2009).
Could exposure to weight stigma have negative health conse-
quences? In a nationally representative study (Sutin & Terrac-
ciano, 2013), weight discrimination was associated with a 2.5-fold
increased risk of becoming obese over 4 years. Weight stigma
could contribute to the development and/or pathophysiology of
obesity independent of adiposity by initiating stress processes, as
social⫺evaluative threat triggers hypothalamic⫺pituitary⫺adre-
nocortical (HPA) axis activation (Dickerson & Kemeny, 2004).
Hypercortisolism drives overeating, increased adiposity, and is
implicated in conditions comorbid with obesity, including Type 2
diabetes and cardiovascular disease (Muennig, 2008). Weight
stigma is associated with higher cardiovascular reactivity (Major,
Eliezer, & Reick, 2012) and modulates the relationship between
central adiposity and glycemic control (Tsenkova, Carr, Schoeller,
& Ryff, 2011). Our first aim, therefore, was to test whether weight
stigma relates to increased cortisol indices. Secondly, stigma pro-
cesses may affect disease risk factors in addition to cortisol. Racial
stigma has been associated with increased oxidative stress (Szan-
ton et al., 2012), a pathogenic mechanism underlying numerous
disease states comorbid with obesity (Basu, 2008). Increased
stress-related hormones, including cortisol, may disrupt the activ-
ity of antioxidant enzymes (Patel et al., 2002). Our second aim,
therefore, was to provide an initial test of whether weight stigma
relates to oxidative stress.
Method
The parent study of the current study was a randomized waitlist-
controlled trial of a mindfulness-based intervention for stress eat-
ing (Daubenmier et al., 2011). The current analyses include all 47
women from the parent study who completed the measures below,
all collected prior to randomization. The University of California,
San Francisco, Committee on Human Research approved all pro-
cedures, and all participants provided written informed consent.
Eligibility criteria were: body mass index (BMI) of 25–40 kg/m
2
;
premenopausal; no history of diabetes, cardiovascular disease, or
active endocrinologic disorder; not pregnant or less than 1 year
postpartum; no prior/current meditation or yoga practice; not cur-
rently on a diet plan; no current self-reported eating disorder,
alcohol, nicotine, or drug addiction; and not taking opiates, ste-
roids, or antipsychotic medications.
Eligible participants underwent two in-lab baseline assessments,
which included dual-energy x-ray absorptiometry (DEXA), and
responded to questionnaires at home. Nursing staff measured
height and weight and conducted blood draws. Participants took
home saliva kits and collected samples across 4 days at awakening,
30 min post awakening, and across 3 days hourly between 1:00 and
4:00 p.m., and bedtime. Participants then returned to submit their
saliva samples and provided fasting blood samples.
Measures
See supplemental materials online for methodologic details.
Adiposity. Nursing staff conducted weight and height mea-
surements, and DEXA assessed abdominal and total body fat.
Weight stigma. To capture both exposure to and conscious-
ness of weight stigma, we used two scales and also created a
composite score. The Stigmatizing Situations Inventory (Myers &
Rosen, 1999) measures how often respondents experienced 50
specific weight-stigmatizing situations. Cronbach’s alpha was .94.
The Stigma Consciousness Scale (Pinel, 1999), which measures
consciousness of stigma due to race/gender/sexual orientation, was
adapted for weight stigma. Cronbach’s alpha was .80. To capture
the total experience of weight stigma, we calculated a sum score of
the two measures’ z scores. The Cronbach’s alpha of this compos-
ite measure was .95.
Cortisol. Salivary free cortisol samples were collected using
standard diurnal cortisol sampling protocols. We derived three sali-
vary cortisol indices: (a) total daily secretion using the area-under-
the-curve-g formula (Pruessner, Kirschbaum, Meinlschmidt, & Hell-
hammer, 2003), (b) cortisol awakening response (CAR), by
subtracting the waking sample from the 30-min sample, and (c)
diurnal slope, the bedtime value subtracted from the waking value
(lower numbers indicate steeper slope). Serum cortisol concentrations
were measured from fasting morning blood samples.
Oxidative stress. F
2
-isoprostane levels assessed systemic in
vivo oxidant stress status (Milne et al., 2007). Blood was collected
in 10 ml ethylenediaminetetraacetic acid tubes, centrifuged, di-
vided into 2-ml aliquots, and stored immediately at ⫺80°C.
Covariates. Self-reported income, self-reported education,
and global perceived stress, as measured by the Perceived Stress
Scale (Cohen, Kamarck, & Mermelstein, 1983), were included in
analyses as possible confounding variables.
Results
Descriptive statistics appear in Table 1. See supplemental ma-
terials online for detailed results. To isolate the association of
weight stigma with cortisol and oxidative stress, multivariate re-
gression analyses modeled the relation between predictor and
outcome variables controlling for abdominal adiposity, because
abdominal fat in particular has been linked to cortisol levels—both
high (Champaneri et al., 2013) and low (Steptoe, Kunz-Ebrecht,
Brydon, & Wardle, 2004)—and oxidative stress (Pou et al., 2007).
Oxidative stress analyses additionally controlled for age (Jacob,
Hooten, Trzeciak, & Evans, 2013). Analyses adjusted for the
potential confounds of income, education, and global perceived
stress when any were significantly related to either stigma or
outcomes. Perceived stress, however, may be a mediator rather
than a confound, such that weight stigma may contribute to greater
perceptions of perceived stress, which in turn may increase cortisol
levels, consistent with the model put forth by Dickerson and
Kemeny (2004). When perceived stress was related to any out-
come measure, therefore, we also tested mediation models using
the INDIRECT macro available from Preacher and Hayes (2008).
After adjusting for confounds, the composite measure of weight
stigma was positively related to morning serum cortisol levels and
F
2
-isoprostanes (see Table 2
). Weight stigma frequency was pos-
itively related to morning serum cortisol levels and CAR. Weight
stigma consciousness was positively related to morning serum
cortisol levels and F
2
-isoprostanes. Furthermore, perceived stress
mediated the relationship between weight stigma consciousness
and CAR. These effects were similar among those in the lowest
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This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
863
WEIGHT STIGMA, CORTISOL, AND OXIDATIVE STRESS
quartile of BMI (⬍27.7, see supplemental Figure S1) as in the rest
of the sample.
Any effect of experiencing stigmatizing events may be depen-
dent on having higher stigma consciousness (Kaiser, Vick, &
Major, 2006). However, no Frequency ⫻ Consciousness modera-
tion models revealed significant interactions (see supplemental
Results).
Discussion
We observed significant relationships between weight stigma
and markers of HPA activation and oxidative stress. Even after
accounting for adiposity, weight stigma was positively related to
two independent indices of cortisol output (from a blood draw and
CAR on separate days) and F
2
-isoprostane levels, an indicator of
oxidative stress. Specifically, the frequency of experiencing weight
stigma was positively related to both morning cortisol indices, and
consciousness of weight stigma was positively related to oxidative
stress in addition to morning cortisol levels. When combined, the
composite measure of weight stigma was positively related to both
morning cortisol levels and oxidative stress. We found that ab-
dominal adiposity was associated with cortisol and oxidative
stress, as found in prior studies (e.g., Steptoe et al., 2004; Pou et
al., 2007); however, weight stigma was associated with morning
serum cortisol and oxidative stress above and beyond that ac-
counted for by abdominal or total adiposity. Oxidative stress
unfolds slowly and is proximal to disease outcomes, suggesting
that weight stigma may contribute to the development of chronic
disease. Indeed, our sample had higher levels of F
2
-isoprostanes
than healthy normal adults, suggesting that both adiposity and
perceptions of stigma may increase oxidative stress levels among
overweight and obese women (60 vs. 35 pg/ml; Milne et al., 2007).
Taken together, these findings are consistent with a novel idea that,
in addition to the well-recognized health effects of adiposity, living
with weight stigma in itself may contribute to obesity pathophys-
iology.
Our findings are somewhat consistent with Szanton et al.
(2012), who found positive associations between racial discrimi-
nation and oxidative stress, although they used only a measure of
frequency of experiencing stigma. We also found a significant
positive association between frequency of experiences with weight
stigma and oxidative stress but not after controlling for adiposity.
In the case of weight stigma, it may be more difficult to disentan-
gle the effects of excess adiposity on the relation between fre-
quency of stigmatizing events and oxidative stress. Greater adi-
posity may influence both exposure to stigmatizing events and
oxidative stress, thereby accounting for the relation between fre-
quency of stigmatizing experiences and oxidative stress. Interest-
ingly, exposure to stigmatizing situations but not consciousness of
weight stigma was related to total adiposity (see supplemental
Table S1), lending some support to this alternative hypothesis.
However, the standardized coefficients for stigmatizing events
were on par with those of stigma consciousness, which remained
significant after controlling for adiposity (Table 1), suggesting
weight stigma frequency may have also been significantly related
to oxidative stress given more power to detect such a relationship,
such as a larger sample.
Table 1
Descriptive Statistics
Variables % or MSDMinimum Maximum
Age (years) 40.89 7.32 21.00 50.00
Body mass index (kg/m
2
)
31.35 4.76 24.89 42.62
Abdominal fat (g) 2,119.47 651.93 999.00 3,610.00
Race
White 61.70
Asian/Pacific Islander 19.10
Hispanic/Latino 14.90
Other 4.30
Income 5.36 1.61 1 7
Education 1.85 0.98 1 4
Perceived Stress Scale 1.90 0.59 0.40 3.5
Weight stigma
Composite (z-score) 0.01 0.44 ⫺0.64 1.14
Stigmatizing situations 89.00 33.36 52.00 193.00
Stigma consciousness 40.27 7.58 26.00 57.00
Cortisol
Morning serum (g/dl) 9.97 1.48 4.18 22.20
Daily total AUC (nmol/L) 9.03 1.42 4.39 27.11
Awakening response (nmol/L) 8.50 1.84 1.82 22.65
Diurnal slope (nmol/L) ⫺14.59 5.58 ⫺5.81 ⫺28.97
F
2
-isoprostanes (ng/ml)
0.06 0.03 0.03 0.20
Note. Stigma variables represent sum scores. Q-Q plots indicated cortisol and F
2
-isoprostane values were
non-normal and were natural-log-transformed. One participant with a body mass index (BMI) higher than our
inclusion criterion of 40 kg/m
2
was included due to a discrepancy between self-reported BMI during the
eligibility screening and BMI measured in the lab. AUC ⫽ area under the curve. Income categories were
represented as 1 ⫽ Under $25,000, 2 ⫽ $25,000–$34,999, 3 ⫽ $35,000–$49,999, 4 ⫽ $50,000–$74,999, 5 ⫽
$75,000–$99,999, 6 ⫽ $100,000–$149,999, and 7 ⫽ Above $150,000. Educational attainment categories were
represented as highest level of education completed, with 1 ⫽ Less than 12 years, 2 ⫽ High school graduate,
3 ⫽ Some college or technical school, 4 ⫽ AA degree, 5 ⫽ Bachelor’s degree, and 6 ⫽ Advanced degree.
This document is copyrighted by the American Psychological Association or one of its allied publishers.
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864
TOMIYAMA ET AL.
Table 2
Multiple Regression Results of Weight Stigma and Outcome Measures Adjusting for Abdominal Fat and Other Confounds
Variable Predictor  b SE 95% CI
Composite weight stigma:
frequency ⫹ consciousness
Cortisol
Morning serum (n ⫽ 44) Composite 0.39
ⴱ
0.35
ⴱ
0.15 [0.05, 0.65]
Abdominal fat ⫺0.35
ⴱ
⫺2E
⫺4ⴱ
9E
⫺5
[⫺4E
⫺4
, ⫺2E
⫺5
]
Income ⫺0.06 ⫺0.02 0.04 [⫺0.09, 0.06]
Global stress ⫺0.11 ⫺0.07 0.11 [⫺0.29, 0.14]
Daily total (AUC) (n ⫽ 37) Composite 0.35 0.30 0.15 [⫺0.01, 0.61]
Abdominal fat ⫺0.17 0.00 0.00 [0.00, 0.00]
Income ⫺0.16 ⫺0.04 0.04 [⫺0.12, 0.04]
Global stress 0.23 0.13 0.10 [⫺0.06, 0.32]
Awakening response (n ⫽ 41) Composite 0.31 5.46 2.82 [⫺0.24, 11.17]
Abdominal fat ⫺0.07 ⫺0.001 0.002 [⫺0.01, 0.003
Income 0.15 0.74 0.74 [⫺0.77, 2.25]
Global stress 0.33
ⴱ
4.48
ⴱ
2.02 [0.39, 8.57]
Diurnal slope (n ⫽ 40) Composite 0.14 1.73 2.19 [⫺2.72, 6.18]
Abdominal fat ⫺0.24 ⫺0.002 0.001 [⫺0.01, 0.001]
Income ⫺0.04 ⫺0.15 0.60 [⫺1.36, 1.07]
Global stress ⫺0.27 ⫺2.46 1.57 [⫺5.64, 0.72]
F
2
-isoprostanes (n ⫽ 44)
Composite 0.32
ⴱ
0.26
ⴱ
0.12 [0.01, 0.51]
Abdominal fat 0.22 0.00 0.00 [0.00, 0.00]
Age ⫺0.20 ⫺0.01 0.03 [⫺0.02, 0.004]
Income ⫺0.03 ⫺0.01 0.034 [⫺0.08, 0.06]
Global stress 0.09 0.05 0.09 [⫺0.12, 0.23]
Weight stigma frequency
Cortisol
Morning serum (n ⫽ 44) Frequency 0.36
ⴱ
0.004
ⴱ
0.002 [9E
⫺5
, 0.01]
Abdominal fat ⫺0.38
ⴱ
⫺2E
⫺4ⴱ
1E
⫺4
[⫺4E
⫺4
, ⫺3E
⫺5
]
Income ⫺0.05 ⫺0.01 0.04 [⫺0.09, 0.07]
Daily total (AUC) (n ⫽ 37) Frequency 0.32 0.004 0.002 [⫺0.001, 0.01]
Abdominal fat ⫺0.21 0.00 0.00 [0.00, 0.00]
Income ⫺0.15 ⫺0.04 0.04 [⫺0.12, 0.05]
Awakening response (n ⫽ 41) Frequency 0.38
ⴱ
0.08
ⴱ
0.04 [1E
⫺4
, 0.17]
Abdominal fat ⫺0.16 ⫺0.002 0.002 [⫺0.01, 0.002]
Income 0.25 1.15 0.78 [⫺0.44, 2.73]
Diurnal slope (n ⫽ 40) Frequency 0.12 0.02 0.03 [⫺0.04, 0.08]
Abdominal fat ⫺0.24 ⫺0.002 0.001 [⫺0.01, 0.001]
Income ⫺0.08 ⫺0.27 0.62 [⫺1.52, 0.99]
F
2
-isoprostanes (n ⫽ 44)
Frequency 0.26 0.002 0.002 [⫺0.001, 0.01]
Abdominal fat 0.23 0.00 0.00 [0.00, 0.00]
Age ⫺0.07 ⫺0.003 0.01 [⫺0.02, 0.01]
Income ⫺0.09 ⫺0.02 0.03 [⫺0.08, 0.05]
Weight stigma consciousness
Cortisol
Morning serum (n ⫽ 45) Consciousness 0.33
ⴱ
0.02
ⴱ
0.01 [5E
⫺4
, 0.03]
Abdominal fat ⫺0.25 0.00 0.00 [0.00, 0.00]
Global stress ⫺0.13 ⫺0.09 0.11 [⫺0.30, ⫺0.13]
Daily total (AUC) (n ⫽ 38) Consciousness 0.32 0.02 0.01 [⫺0.002, 0.03]
Abdominal fat ⫺0.07 0.00 0.00 [0.00, 0.00]
Global stress 0.17 0.10 0.10 [⫺0.10, 0.30]
Awakening response (n ⫽ 42) Consciousness 0.24 0.25 0.16 [⫺0.08, 0.057]
Abdominal fat ⫺0.03 0.00 0.002 [⫺0.004, 0.003]
Global stress 0.36
ⴱ
4.83
ⴱ
2.02 [0.73, 8.92]
Diurnal slope (n ⫽ 41) Consciousness 0.10 0.07 0.12 [⫺0.18, 0.33]
Abdominal fat ⫺0.20 ⫺0.002 0.001 [⫺0.004, 0.001]
Global stress ⫺0.27 ⫺2.53 1.54 [⫺5.64, 0.59]
F
2
-isoprostanes (n ⫽ 45)
Consciousness 0.33
ⴱ
0.02
ⴱ
0.01 [0.002, 0.03]
Abdominal fat 0.28
ⴱ
1E
⫺4ⴱ
7E
⫺5
[1E
⫺6
,3E
⫺4
]
Age ⫺0.25 ⫺0.01 0.01 [⫺0.03, 0.001]
Global stress 0.06 0.03 0.09 [⫺0.14, 0.21]
Note. Cortisol units are ln(mg/dl) for serum and ln(nmol/L) for saliva; F
2
-isoprostane units are ln(ng/ml). Beta values are standardized units; b values are
raw values. Unadjusted analyses are available in supplemental Table 2.CI⫽ confidence interval; AUC ⫽ area under the curve. We provide values to more
than three decimal places only when p ⬍ .05.
ⴱ
p ⬍ .05 (two-tailed).
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865
WEIGHT STIGMA, CORTISOL, AND OXIDATIVE STRESS
