“I Feel Like Less of a Mom”: Experiences of Weight Stigma by Association among Mothers of Children with Overweight and Obesity

Abstract

Background:

Parents of children with higher weight are blamed and shamed for their children's weight. However, parents' experiences of this form of stigma, termed weight stigma by association, are poorly understood. The objective of this study was to investigate the sources, forms, and impacts of weight stigma by association among mothers of children with overweight or obesity.

Methods:

In this qualitative study, mothers who reported concern about their children's weight participated in semistructured interviews administered by the research team. A coding scheme was developed and reliably applied to interview transcripts. Mothers' self-reported sociodemographic information, and height and weight were measured.

Results:

Thirty-four mothers (M_age: 43.4 years; 26.5% non-Hispanic Black or African American, 70.6% with obesity) participated in the study. Mothers reported that family members were a common source of negative comments about their children's weight; these comments were often critical of mothers' parenting and in some cases contributed to negative affect among mothers. Many mothers also reported negative experiences during children's physicians' visits as a result of their children's weight. Almost all mothers expressed guilt and sadness for their perceived role in their children's weight status, expressing regret that they did not parent differently.

Conclusions:

Mothers of children with overweight and obesity are frequently the target of weight stigma by association and experience negative cognitions and emotions regarding their perceived role in their children's weight. Continued research is needed to elucidate the impacts of stigma by association due to child weight on parents' health, the parent/child relationship, and children's health.

Introduction

Weight stigma, one of the most prevalent and pervasive forms of stigma in the United States,¹ is driven by the belief that individuals of higher weight are lazy, lacking in self-control, and uninterested in their health, and thus to blame for their weight.^2–4 While some believe that weight stigma can motivate behavior change,⁵ a robust literature indicates that weight stigma contributes to poor mental and physical health, including anxiety, depression, cardiometabolic dysregulation, and even increased mortality.^6–8

Parallel to the belief that individuals are to blame for their weight, it is commonly believed that parents, and specifically mothers,⁹ can and should control their children's weight,¹⁰ and that childhood obesity is caused by poor parenting.^11–13 Parents of children with higher body weight have been described as inept, neglectful, and uncaring,¹³ and children with larger bodies have been described as “visible markers of parental irresponsibility.”¹⁴ Physicians' opinions mirror those of the general public with 69% of pediatricians reporting that parents are to blame for childhood obesity.¹⁵ This blame is exacerbated by antiobesity public health campaigns¹⁶ and the media,^9,17,18 which frequently portray children of higher weight as “victims” of poor parenting and specifically, failed mothering.

Although some believe that attributing blame for children's weight to parents is appropriate, negative attitudes and behaviors directed toward parents of children with obesity are a form of stigma by association.¹⁹ Stigma by association, also referred to as courtesy stigma, has been described as a stigma that is “spread out in waves” to family members and others close to stigmatized individuals.²⁰ Stigma by association occurs when individuals are devalued because of their connection to someone with a stigmatized condition or identity.¹⁹ Stigma by association and its management have been most commonly studied among family members of individuals with mental illness.^21–27 This body of research describes how stigma by association contributes to lower self-esteem, stress, and psychological distress among caregivers and adversely affects interpersonal and familial relationships.^21–26 Furthermore, similar to individuals who are stigmatized because of a condition or identity that they themselves hold, individuals who experience stigma by association rely on a variety of methods to manage the stigma, including “passing,” or trying to conceal what is prompting stigma, and covering, or minimizing the obtrusiveness or visibility of what is prompting stigma.²⁰

One mechanism by which stigma by association harms individuals and families is that some individuals who have been the target of stigma by association internalize the blame, shame, and devaluation directed toward them, believing that they are incompetent and inferior to others and becoming ashamed of their identity.²⁸ This internalization of stigma by association, referred to by some as “affiliate stigma,”²⁹ contributes to depression and anxiety, and disrupts relationships between caregivers and those with the stigmatized condition.^29–33 The effects of caregivers' internalization of stigma by association are evident in a recent study of parents of children with Attention Deficit Hyperactivity Disorder (ADHD).³² ADHD is a condition, which, similar to childhood obesity, is believed by some to be caused by suboptimal, lax parenting. In this study, parents who reported greater internalization of stigma by association, that is, those who experience more self-blame and shame due to their child's condition, displayed more negativity toward their children, even after accounting for children's degree of ADHD symptoms.

Only a small number of studies^14,34,35 have assessed parents' experiences of stigma by association due to child weight status. Jackson et al.³⁴ found that mothers of children with obesity felt blamed by and isolated from family and friends because of their children's weight. Furthermore, Hamlington et al.³⁵ identified that parents of children with obesity often felt judged by their children's health care providers and that their perspectives were dismissed in medical settings. Finally, in a recent study of parents of children participating in a weight loss camp, many parents provided explicit examples of being blamed and shamed due to their child's body weight.¹⁴

Given the limited research on stigma by association among parents of children with higher body weight, the objective of this study was to qualitatively investigate the sources, forms, and impacts of weight stigma by association directed at mothers who identify as having a child or children with overweight or obesity. This study focused on mothers as previous research has identified that mothers are most affected by stigma by association³⁶ and, similar to other health conditions, mothers experience the most blame for their children's weight.^16,37 This exploratory research is essential to expand our understanding of parents' experiences of weight stigma by association, guide future efforts to quantify weight stigma by association, and ultimately, identify the impacts of weight stigma by association on parent and child health and family functioning.

Methods

Participants and Procedures

Mothers of children 5–16 years of age who reported feeling concerned about their child/children's weight were invited to participate in the study. This age range of children was selected because it was hypothesized that for children younger than 5 years, excess weight may be perceived as advantageous or desirable,³⁸ and parents would not be the target of negativity from others. Meanwhile, children older than 16 years may be viewed as primarily responsible for their own weight, so blame toward parents of older adolescents may be attenuated. Mothers who reported concern about their child/children's weight were enrolled to increase the likelihood that questions regarding experiences and emotions around children's weight would be salient.

Two recruitment methods were used: an advertisement on the University of Michigan health system's online research participant recruitment database (UMHealthResearch.org), which notifies members of the community about research engagement opportunities, and contacting mothers of children with overweight and obesity who recently completed a study of child feeding.³⁹ For both methods, individuals interested in study participation completed a brief screening and were eligible if they identified as a mother or female caregiver, had at least one child between the ages of 5 to 16 whom they identified as having overweight, reported being at least “concerned” about their child's weight, reported that English was their primary language at home, and could attend a study visit at the University of Michigan. All participants therefore lived in or in close proximity to Ann Arbor, Michigan. Two hundred three individuals were screened for eligibility, 77 (38%) were eligible, and 34 (17%) completed the study between June and November 2018. Although a pool of eligible participants remained after 34 interviews, enrollment was concluded because research staff identified that newly enrolled mothers were providing similar information during the semistructured interviews as mothers who previously participated, indicating that saturation of ideas had been achieved.⁴⁰

Trained research staff conducted individual study visits that consisted of mothers completing study questionnaires through REDCap (Research Electronic Data Capture)⁴¹ to capture sociodemographic information, an audio-recorded semistructured interview, and measurement of mothers' height and weight from which BMI (kg/m²) was calculated. The study was approved by the University of Michigan's Institutional Review Board and mothers provided informed and written consent to participate. Mothers were informed that due to the sensitive nature of the topic, some questions may cause discomfort and that they could skip questions or end the study visit at any time. Mothers received a $30 gift card as compensation for participating.

At the beginning of the one-on-one semistructured interview, mothers were asked how many children they had between the ages of 5 and 16. For each of these children, mothers were then asked to provide words or phrases that described their children's weight or body shape. The children whom mothers described using words indicative of higher weight and/or larger body size (e.g., fluffy, overweight, big, and thick) became the focus of the interview. The interview guide, provided in Supplementary Table S1, was developed by the study team guided by themes identified in a review of the literature regarding individuals' experiences of weight stigma and caregivers' experiences of stigma by association. The interview questions were designed to elicit discussion about mothers' feelings regarding their children's weight, comments, or actions directed at them or their children because of their children's weight, attributions about pediatric obesity in general, and attributions about their children's weight. Questions that most often elicited information relevant to the study objectives are listed below; however, mothers' responses to all of the interview questions were reviewed and coded to understand experiences of stigma by association and stigma internalization: 1.

Has anyone in your family ever said anything about your child's weight? If yes, what do they say? How do you feel when they say these things?

Has your child's doctor ever said anything to you about your child's weight? If yes, what types of things have your child's doctor said to you about their weight? How did you feel when they said these things?

Have any other adult ever said anything about your child's weight? If yes, what have they said? How does that make you feel?

Some people think that parents are to blame when a child is overweight. How does that make you feel? Do you think that other people blame you for your child's weight? What makes you think that?

Analysis

Univariate statistics were calculated using SAS 9.4 (Cary, NC) to describe mothers' sociodemographic characteristics and weight status classified using recommended cut points with overweight as a BMI of ≥25 and <30, class I obesity as a BMI of ≥30 and <35, class II obesity as a BMI of ≥35 and <40, and class III obesity as a BMI ≥40.

Using the constant comparative method,⁴² two research staff (J.C.G. and C.V.G.) first independently reviewed transcripts of the semistructured interviews and recorded common themes in mothers' responses. These research staff and study investigators (N.A.S. and K.W.B.) then met to discuss possible themes, combine themes that were repetitive or too narrow (e.g., only one to two mothers presented the idea), rectify disagreements, and identify illustrative quotes for each of the themes. This process resulted in an initial coding scheme, which the two research staff then independently applied to reliability sets of 4 to 10 interviews using Atlas.ti 8. After completing each reliability set, the two research staff met to examine discrepant codes and edit the coding scheme to improve the specificity and clarity of codes. Once the two research staff achieved at least 80% agreement on all codes, the remaining interviews were double coded. Any remaining discrepancy between the two research staff was discussed with a study investigator (K.W.B.) and the final assigned theme(s) agreed on.

Results

Participants' sociodemographic and weight status characteristics are presented in Table 1. On average, mothers were 43.4 years old (SD = 7.3). Over half of mothers identified as non-Hispanic White (55.9%), 26.5% identified as non-Hispanic Black or African American, 11.8% identified as Hispanic/Latina, and 5.9% reported identifying as mixed race or another non-Hispanic race. Most mothers had obtained a bachelor's degree (44.1%) or a graduate degree (23.5%) and most (61.8%) reported household incomes of $75,000 or higher. The majority (70.6%) had a BMI in the obese range (11.8% in the obesity class I range, 29.4% in the obesity class II range, and 29.4% in the obesity class III range).

Table 1.

Sociodemographic and Weight Status Characteristics of Study Sample (N = 34)

Age, mean (SD), range	43.4 (7.3), 28.6–55.6
Race/Ethnicity, %
Non-Hispanic White	55.9
Non-Hispanic Black/African American	26.5
Hispanic/Latina	11.8
Non-Hispanic mixed race or another race	5.9
Educational attainment, %
Completed high school	20.6
Obtained associate's degree	11.8
Obtained bachelor's degree	44.1
Obtained graduate degree	23.5
Household income, %
Under $35,000	17.7
$35,000 to < $50,000	5.9
$50,000 to < $75,000	11.8
$75,000 or higher	61.8
Don't know/refused	2.9
Weight status
BMI <25	17.7
Overweight	11.8
Obesity class I	11.8
Obesity class II	29.4
Obesity class III	29.4

SD, standard deviation.

Stigma by Association from Family

Most mothers (79.4%) reported that family members, often their parents, in-laws, and children's fathers, commented to them about their children's weight. Two-thirds (66.7%) of the mothers whose family members commented to them about their children's weight reported that family members had made shaming comments to them because of their children's weight; most often these comments were about how mothers' parenting practices contributed to or exacerbated their children's higher weight. Consistently, mothers shared stories of how their family members “question their parenting skills” and tell them they have to “get it under control,” referring to their child's weight. Mothers have been asked by family, “Why is she so fat?” and have been told they have to “do something about it.” One mother was told, “this is your responsibility,” while another shared that her parents tell her, “We don't like the way you parent,” and that she should be stricter with her daughter. A similar experience was repeated by another mother who had been told by her family, “You really should watch what he's doing. Why aren't you stopping him from eating?” Similarly, one mother was asked by family, “Why are you feeding [child] so much?” Specifically, the belief that mothers are too lax with their children or “spoiling” them was common, with mothers frequently reporting that their family members think they give their children “whatever they want.” For example, one mother said of her parents,

They definitely imply it's my fault, like I'm not doing a good enough job. I'm not in control enough of what she eats or her exercise or her diet and my parents would say that that's definitely one-hundred percent my fault, like not [child's] fault. And so then, they just kinda treat me like, well, you're, you know, not the greatest parent.

A minority of mothers (7.4%) whose family members made comments to them about their children's weight said that they appreciated the comments and suggestions for how changes in their parenting could improve their child's weight. These mothers said that the comments demonstrate that their family cares about their child and affirm their own concerns about their child's weight. One mother reported that she did not mind the comments because they were “nothing over the top.” Others attributed their family members' concern, to a family history of higher weight and desire to protect their children from health problems later in life. Mothers who said that they were not bothered by the advice often also added that they do not feel they are to blame for their children's weight. For example, one mother shared, “nobody's derogatory or feels that there's anything… that I've done or that they've done that's caused this.”

In contrast, the majority of mothers (51.6%) who reported comments from family about their children's weight found the comments hurtful and made them sad, angry, embarrassed, and in one case, “numb.” In response to her child's father criticizing her, one mother said, “It upset me to be blamed directly, even though I may feel that way, just to hear it out loud coming from someone else.” Another mother said that her own mother's negative comments made her “feel like a crappy parent.”

The remainder of mothers who reported comments from family about their children's weight were not sure how they felt about these comments, with some sharing that they had not really thought about how they felt.

Some mothers believed that they could not say anything in response to the criticism (e.g., “There's nothing I can do, it's the elders of the family so I gotta take it… but I'm cringing.”), whereas other mothers feel able to tell their family members the comments are upsetting (e.g., “I make it known, it's frustrating and inappropriate” and “I nipped that in the bud.”). Several mothers noted that their family members were “hypocrites” for criticizing their parenting, but engaging in the same parenting behaviors themselves. For example, one mother responded to her parents, “When I was hungry, you fed me, didn't you?” Some mothers discussed how family criticism of their parenting contributed to significant disruptions of family relationships. When asked how her family's comments about her child's weight and her role in it made her feel, one mother shared the following:

I'd like to punch them in the throat to be honest.… I've really stopped hanging out with my family. It's caused a huge rift…. I have become very isolated through all this, especially with my family.

Stigma by Association by Children's Physicians

When asked about interactions with their children's doctors, one-third of mothers expressed negative feelings about their children's physicians, either because of previous negative interactions regarding their children's weight or anticipatory fear of future negative interactions. These mothers expressed feelings of blame, embarrassment, and shame when interacting with their children's physicians. Some mothers shared that they “dread” making appointments for their children because they know they are going to get “the lecture” about their children's weight.

Many mothers recalled specific negative comments that physicians had made to them about their child's nutrition or weight, with some expressing frustration that physicians incorrectly assumed they were feeding their children unhealthy foods. Feeling unheard and questioned by physicians, particularly with respect to children's diets, was a common experience by mothers. One mother shared that these interactions put her on the defensive and she would hope that after seeing the same provider for several years, the provider would believe that unhealthy foods were not available in her home. Just as family members' criticisms made mothers feel like they were not good parents, mothers shared that physicians' comments about their children's weight and health made them feel hurt and “bad as a mom.” One mother said, “It just makes me feel like I'm less than a mom…. Like I didn't make the right choices for them and that's why they're like that.”

Some mothers discussed how routine practices, such as weighing children or counseling regarding screen time, elicited fear and shame. Mothers understood why their children's physicians were doing these things, but this recognition did not mitigate feelings of blame. One mother said she agreed with her child's physician that she lets her child watch too much television and felt the provider was “doing his job” by discussing screen time, but that the conversation still made her feel bad. Another mother similarly said her child's doctor was easy to talk with, but that she still gets nervous before appointments out of fear that she'll get asked, “What are you feeding this kid?” Still, another mother said her child's physician was “very, you know, nice about it” when talking about her child's weight, but that the conversations made her “feel as a parent like crap…. Like my child's not perfect and it's my fault.” Similarly, another mother said, “there's that mom guilt” after receiving nutrition and physical activity counseling for her child.

Stigma by Association by Other Adults

When asked, a small number of mothers (14.7%) reported being the target of negative comments about their children's weight by adults who were not their family or their child's physician. These individuals included co-workers, restaurant wait staff, and parents of other children. One mother shared that she received unsolicited advice from a co-worker about how she needs to change her child's diet because the co-worker assumed the child was developing hypertension and diabetes. This interaction was embarrassing for the mother and, similar to comments by family members and physicians, made her “feel like I'm not being a good mom.”

Attribution of Blame for Children's Weight

Almost all mothers (85.3%) reported that they are, at least in part, to blame for their children's weight and felt that they should have parented differently to protect their children's health. One mother said, “We're supposed to be breaking cycles but like we've like perpetuated this one I guess. Just kinda feel like a failure.” In almost all cases where mothers felt blamed by others for their children's weight, mothers said they're deserving of the blame. For example, one mother said,

I mean they're kids. We buy their food, we're responsible for their daily routine and I mean they can't make those decisions on their own, so I kind of feel like in a way we are to blame.

A small proportion of mothers became visibly upset and/or cried during the interview (11.8%), particularly when describing how they blame themselves for their children's weight.

Several mothers also reflected on their own weight and how that affected their responsibility for their children's weight. Mothers of higher weight shared that they felt particularly responsible for their children's weight because they had higher weights themselves. For example, one mother said, “I don't know if it's like worse since I'm fat or if it would be worse like, oh if you're thin and you let your kid get fat.” Furthermore, some perceived that the devaluing of their parenting by others was more hurtful because of their weight. One mother reflected that because she is overweight, she “might take things more personally than the average joe.”

Despite the pervasive self-blame, many mothers also mentioned factors that contribute to their children's weight outside of their control. Several mothers of older children commented that it is difficult to control teenagers' behaviors (e.g., “she's at that age where she will just go make whatever she wants.”) and now that the children are older, their eating and weight are their own responsibility. One mother said, “as they get older, I think it's less the parents and more those choices that have already been ingrained for a bad lifestyle.” Other mothers discussed how genetics, their child's high drive to eat, and the food served in school and available in the community make regulating their children's weight difficult. For example, one mother said, “I mean in terms of genetics, there's nothing I coulda done,” and another said, “I think it's because he's going through a depression by losing his father 8 years ago, so he loves to eat.” And finally, another mother shared, “…you know, we're fairly poor. We do get food stamps and you know it's hard to eat healthy on food stamps.” Meanwhile, despite these circumstances, many of the mothers felt that others believe they can, and should, have control of their children's eating and weight.

Discussion

Reflecting public opinion that parents are responsible for childhood obesity,¹¹ nearly all mothers perceived that they are to blame for their children's weight. Comparing responses across questions about interactions with family, physicians, and other adults, family members were the most common and explicit source of criticism directed toward mothers about their children's weight. A meaningful proportion of mothers also reported negative experiences with or feelings about their child's physician due to their child's weight. Self-blame and sadness were pervasive among the study sample, with many mothers reporting that their child's weight reflects their parenting failures. Most mothers believed that others' blame of them was justified.

Study findings reflect those of Jackson et al.³⁴ In both studies, many mothers reported being the target of negative comments about their child's weight by family members. While some mothers reported that family members' comments were well meaning and even affirming of concerns that mothers themselves had, the majority reported the comments were critical and unwanted. The hurtful interactions and social isolation that mothers experience due to stigma by association are stressful and may interfere with receipt of social support and resources, particularly in families where members avoid spending time together. Further research is needed to understand how family members can support parents of children of higher weights without inducing shame and hurt.

Physicians were another source of perceived stigma by association through both direct comments to mothers as well as subtle behaviors that made child weight salient. Even the anticipation of judgment or blame caused anxiety among mothers. Prior weight stigma research suggests that anticipation of blame or judgment could lead to the delay or avoidance of health care.⁴³ Given that some mothers reported that nutrition counseling for their child was perceived as blaming, it is important to elucidate potential iatrogenic effects of pediatrician weight and nutrition counseling and identify counseling approaches that mothers perceive as respectful, size inclusive, and nonshaming. This may be challenging as the pervasive blaming of parents from society at large may contribute to parents' increased consciousness of and sensitivity to perceived blame, irrespective of provider behavior. However, targeted training for pediatric providers regarding the multi-factorial etiology of obesity and the harms of even subtle forms of weight stigma may reduce stigmatizing behaviors by providers.^44,45

The majority of mothers expressed self-blame for their child's weight, despite acknowledgment that other factors contribute to child weight. Some mothers who did not report specific stigmatizing experiences still described self-blame for their children's weight and verbalized that their children's weight was a product of their poor parenting. This may reflect that the interview, which focused on stigma by family, physicians, and other adults, did not fully capture the range of experiences of stigma by association directed at parents. This finding could also reflect that mothers may not be conscious of or able to describe specific times that they have experienced stigma, yet the pervasive stigma directed at parents of children of higher weight can still be internalized. Given the harms of internalizing weight bias among adults with obesity,⁴⁶ and recent research suggesting that parents' internalized bias about their own higher weight may prompt harmful child-directed conversations about weight,⁴⁷ it is essential to understand the consequences of parents' internalization of weight stigma by association. Specifically, it is important to identify whether attribution and internalization of blame for child weight are associated with harmful parenting practices, such as restrictive dietary rules, weight-shaming or teasing, or singling out a child of higher weight.

Limitations of the study include that most participants were recruited through the University of Michigan health system's research participant recruitment database, and therefore may have been more motivated to participate in research than the general public. In addition, most participants reported relatively high household incomes and educational attainment, which limit our understanding of the experiences of lower-socioeconomic status families. Particularly, as obesity is more prevalent among some lower-income populations⁴⁸ and previous research has identified that lower-income families are more likely to talk about weight than higher income families,^49,50 it would be useful to understand how the prevalence and forms of stigma by association differ by family socioeconomic status. Furthermore, the study only focused on mothers' experiences. Fathers may experience stigma by association and stigma internalization in different ways than mothers; future research is needed to elucidate these differences.

The study also specifically recruited mothers who were concerned about their child's weight. It may be that mothers who are concerned about their child's weight have heightened consciousness of and sensitivity to others' negative attitudes or blame. Mothers not concerned about their children's weight may also be less likely to have experienced stigma by association. Many mothers also had obesity themselves and therefore may have been more likely to internalize negative weight-based stereotypes that are then extended to their children.¹⁴ Finally, the phrasing of interview questions, particularly regarding mothers' experiences of blame due to their children's weight, may have impacted mothers' responses, and some hypothesized impacts of stigma by association, such as how these experiences affect parenting and the parent-child relationship, were not prompted for by interview questions.

Given the lack of measures of weight stigma by association, an important next step is to develop a quantitative tool with which to systematically assess experiences of stigma by association and internalized stigma by association among parents of children with higher weight, similar to measures of weight stigma⁵¹ and weight stigma internalization^52,53 directed toward individuals of higher weight. This tool will enable empirical identification of how stigma by association and stigma internalization affect the parent-child relationship, parenting practices, and parent and child mental and physical health. Future research should also specifically assess how the experience of and internalization of parent blame differ across families to identify factors that confer resilience against the impacts of stigma by association. For example, parents who do not overvalue their children's weight, that is, those who do not feel that their children's weight reflects the quality of their parenting,⁵⁴ may be less likely to internalize stigma by association and experience its potentially harmful effects. Finally, it is essential to develop and test communication strategies for family members and health care providers to ensure that child health-related concerns are addressed sensitively and effectively with parents of children with overweight and obesity.

Footnotes

Funding Information

This research was supported by American Heart Association Grant-in-Aid Award 17GRNT33350079 (PI: Katherine W. Bauer) and NIH UL1TR002240 (PI: Mashour).

Author Disclosure Statement

No competing financial interests exist.

Supplementary Material

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