Characterization of Courtesy Stigma Perceived by Parents of Overweight Children with Bardet-Biedl Syndrome

<div><p>Background</p><p>A child’s obesity is generally perceived by the public to be under the control of the child’s parents. While the health consequences of childhood obesity are well understood, less is known about psychological and social effects of having an obese child on parents. We set out to characterize stigma and courtesy stigma experiences surrounding obesity among children with Bardet-Biedl syndrome (BBS), a multisystem genetic disorder, and their parents.</p><p>Methods</p><p>Twenty-eight parents of children with BBS participated in semi-structured interviews informed by social stigmatization theory, which describes courtesy stigma as parental perception of stigmatization by association with a stigmatized child. Parents were asked to describe such experiences.</p><p>Results</p><p>Parents of children with BBS reported the child’s obesity as the most frequent target of stigmatization. They perceived health care providers as the predominant source of courtesy stigma, describing interactions that resulted in feeling devalued and judged as incompetent parents.</p><p>Conclusions</p><p>Parents of children with BBS feel blamed by others for their child’s obesity and described experiences that suggest health care providers may contribute to courtesy stigma and thus impede effective communication about managing obesity. Health care providers may reinforce parental feelings of guilt and responsibility by repeating information parents may have previously heard and ignoring extremely challenging barriers to weight management, such as a genetic predisposition to obesity. Strategies to understand and incorporate parents’ perceptions and causal attributions of their children’s weight may improve communication about weight control.</p></div

Big Five Scores.

<p>Big Five Scores.</p

Demographics of Respondents versus All Participants.

<p>Demographics of Respondents versus All Participants.</p

The effects of the Rgs6 on HRV are mediated by the I_KACh and are influenced by the m₂R activity.

<p>A, Schematic representation of the pathway targeted both genetically and pharmacologically. Abbreviations are: atropine (Atro), carbamylcholine (CCh). B, Effect of m₂R blockade by atropine on HRV in wild-type (black; n = 7) and <i>Rgs6^−/−</i> hearts (red; n = 10). No significant effect of drug was observed in wild-type hearts. C, Increased sensitivity of <i>Rgs6^−/−</i> hearts to m₂R stimulation and its rescue by I_KACh (<i>Girk4</i>) ablation. Increasing concentrations of CCh were applied to isolated perfused hearts (n = 4–6 per genotype). D, m₂R stimulation non-proportionately increased HRV in <i>Rgs6^−/−</i> hearts. Hearts (n = 3–6 per genotype) were perfused with CCh (∼IC₁₀ concentration) identified from dose-response studies, followed by measurement of changes in the RMSSD parameters. Symbols: * P<0.05 vs wild-type, #P<0.05 vs treatment.</p

Essential Role of the m₂R-RGS6-I_KACh Pathway in Controlling Intrinsic Heart Rate Variability

<div><p>Normal heart function requires generation of a regular rhythm by sinoatrial pacemaker cells and the alteration of this spontaneous heart rate by the autonomic input to match physiological demand. However, the molecular mechanisms that ensure consistent periodicity of cardiac contractions and fine tuning of this process by autonomic system are not completely understood.</p><p>Here we examined the contribution of the m₂R-I_KACh intracellular signaling pathway, which mediates the negative chronotropic effect of parasympathetic stimulation, to the regulation of the cardiac pacemaking rhythm. Using isolated heart preparations and single-cell recordings we show that the m₂R-I_KACh signaling pathway controls the excitability and firing pattern of the sinoatrial cardiomyocytes and determines variability of cardiac rhythm in a manner independent from the autonomic input. Ablation of the major regulator of this pathway, Rgs6, in mice results in irregular cardiac rhythmicity and increases susceptibility to atrial fibrillation. We further identify several human subjects with variants in the <i>RGS6</i> gene and show that the loss of function in RGS6 correlates with increased heart rate variability. These findings identify the essential role of the m₂R-I_KACh signaling pathway in the regulation of cardiac sinus rhythm and implicate RGS6 in arrhythmia pathogenesis.</p></div

Abnormal sinus arrhythmia in a human subject with dysfunctional RGS6.

<p>A, HRV measured in humans carrying variants in <i>RGS6</i> and 11 age-matched control subjects (wt, black). Lines represent upper (2σ) and lower (−2 σ) 95% confidence thresholds as determined by the 2σ rule. <i>Insert</i>: domain structure of RGS6 protein. Arrows show localization of corresponding variants. B, Representative tachograms of RR intervals from a control subject (black) and a subject heterozygous for the p.Val13LeufsX11 variant in the <i>RGS6</i> gene (red) determined from continuous Holter recordings. C, Schematics of the assay design to study effects of mutations on the RGS6 function. Stimulation of the m₂R by ACh results in the dissociation of Gμo from the heterotrimer. Released Gβγ subunits tagged with Venus become available for the interaction with Nluc8-tagged GRK reporter producing the BRET signal. D. Representative responses to sequential application of ACh (10 µM) and atropine (1 mM) recorded in the presence of the indicated constructs. The BRET signals averaged from 4 experiments were plotted as individual data points. <i>E</i>, Catalytic activity of RGS6 defined by the <i>k</i>_GAP parameter. To determine the <i>k</i>_GAP values, the deactivation rate constant measured in the absence of RGS6 was subtracted from values measured in the presence of RGS6. Symbols: ***, p<0.001 (n = 4).</p

Rgs6 and Girk4 have opposite effects on HRV in isolated hearts.

<p>A, Average HR in hearts isolated from wild-type (wt, n = 36), <i>Rgs6</i>^−/− (n = 52), and <i>Girk4</i>^−/− (n = 19) mice. B, ECG traces recorded in isolated wild-type (black), <i>Rgs6^−/−</i> (red), and <i>Girk4^−/−</i> (green) hearts. Note rhythm irregularity in <i>Rgs6</i>^−/− hearts. C, Quantification of sinoatrial dysfunction events. D–F, Representative tachograms of baseline ECG in wild-type (black), <i>Rgs6</i>^−/− (red), and <i>Girk4</i>^−/− (green) hearts. G–I, Key HRV parameters in the time and frequency domains from ECG recordings. J–L, Non-linear HRV analysis by Poincare plots for wild-type (J), <i>Rgs6^−/−</i> (K), and <i>Girk4^−/−</i> (L) hearts. Symbols: * P<0.05, ** P<0.01, ***P<0.001 vs. wild-type.</p

Inactivation of <i>Rgs6</i> disrupts cardiac rhythm in mice.

<p>A, Representative tachograms of RR intervals from wild-type (black) and <i>Rgs6^−/−</i> (red) mice recorded by ECG radiotelemetry. B and C, Summary of HRV analysis in conscious, freely-moving mice. D, Burst pacing induced AF in <i>Rgs6^−/−</i> but not in wild-type mice. Note an irregular rhythm with no discernible P waves in the <i>Rgs6^−/−</i> recording. E, Quantification of AF induction probability. Symbols: *, P<0.05.</p

Ablation of <i>Rgs6</i> reduces excitability of sinoatrial cells and disrupts their automaticity.

<p>A, Resting membrane potential measured immediately after obtaining whole-cell access in wild-type (wt), <i>Rgs6^−/−</i>, and <i>Girk4^−/−</i> SAN cells. B, Inward currents evoked by application of acetylcholine (ACh, 100 µM) in SAN cells from wild-type (black), <i>Rgs6^−/−</i> (red) and <i>Girk4^−/−</i> (green, no current) mice. C, Summary of steady-state ACh-induced deactivation kinetics of I_KACh in wild-type and <i>Rgs6^−/−</i> SAN cells (n = 11–15 cells/genotype). D, Representative traces of spontaneous calcium oscillations recorded from wild-type (black; n = 14) and <i>Rgs6^−/−</i> (red, n = 20) SAN cells. Arrows show skipped beats. E, Quantification of SAN arrhythmic events defined as more than 15% change in duration of peak-to-peak interval of spontaneous calcium oscillations in wild-type (n = 11) and <i>Rgs6^−/−</i> (n = 17) SAN cells. F, Reduced frequency of spontaneous calcium oscillations recorded in <i>Rgs6^−/−</i> SAN cardiomyocytes as compared to wild-type (n = 14–20 cells/genotype). G, Increased variability of spontaneous calcium oscillations in <i>Rgs6^−/−</i> SAN cells as determined by increase in RMSSD values (n = 14–20 cells per genotype). Symbols: *P<0.05; **P<0.01; ***P<0.001.</p

Colony survival assay demonstrates cellular radiosensitivity in Patients 2 and 3.

<p>Lymphoblastoid cell lines from Patients 2 and 3 were radiosensitive, as compared to controls. Experiments were performed in triplicate with the average of three experiments shown. WT  =  wild type; A-T  =  ataxia-telangiectasia control. Ligase IV  =  Ligase IV-deficient control.</p