Self-reported Stigmatization Among Candidates for Bariatric Surgery
The popularity of bariatric surgery has increased the focus on the psychological aspects of extreme obesity. Although a growing literature has documented the psychosocial burden associated with extreme obesity, surprisingly little attention has been paid to the experience of weight-related stigmatization among extremely obese individuals. The present study investigated self-reported experiences of weight-related stigmatization, weight-related quality of life, and depressive symptoms among 117 extremely obese individuals (BMI = 48.2 ± 7.5 kg/m2) who presented for bariatric surgery at the Hospital of the University of Pennsylvania. In general, these individuals reported infrequent weight-related stigma, which was unrelated to BMI. Some specific forms of stigmatization, however, appear to be related to body size. The occurrence of stigmatization was associated with poorer weight-related quality of life and greater symptoms of depression.
Presently, 6.9% of US women and 2.8% of US men are extremely obese, defined by a BMI ≥40 kg/m2 (1). Bariatric surgery is believed to be the most effective weight control option for extreme obesity and is currently recommended for individuals 18 years and older with a BMI ≥40 kg/m2 (or a BMI >35 kg/m2 in the presence of significant comorbidities such as coronary heart disease, hypertension, type 2 diabetes, and sleep apnea) (2). The most reliable statistics available suggest that 103,000 individuals underwent bariatric surgery in the United States in 2003 (ref. 3).
The significant health problems associated with extreme obesity likely motivate many individuals to pursue bariatric surgery (4,5). Many extremely obese persons also pursue bariatric surgery for its anticipated effect on psychosocial status (6,7,8,9). Studies have documented a high rate of psychopathology among persons with extreme obesity who pursue bariatric surgery. Approximately 20–60% of patients have been described as suffering from an Axis I psychiatric disorder, the most common of which were mood and anxiety disorders (10,11). Of these disorders, depression may be the most significant. In a population-based study of >40,000 US adults, the risk of major depression in persons with a BMI ≥40 kg/m2 was nearly five times that in persons of average weight (12). The risk of depression among patients seeking bariatric surgery may be even greater, as medical and surgical patients typically report more symptoms of depression than nontreatment-seeking individuals (13). Among bariatric surgery patients, depressive symptoms are associated with greater impairments in quality of life and have been shown to be a predictor of poorer health- related quality of life postoperatively (13,14). Severe, untreated depression is often considered a contraindication to bariatric surgery (15).
The experience of weight-related stigmatization or overt discrimination may contribute to the psychosocial distress seen in persons with extreme obesity. Overt hostility toward, and bias against, obese individuals have been found in social, educational, occupational, and medical settings (16,17,18,19). The frequency of weight-related stigmatization has been positively associated with BMI (20). Severely obese persons, because of their weight and physical limitations, may be particularly likely to experience pervasive and intense stigma and the resultant psychological distress. A history of weight-based teasing, one of the more overt experiences of stigma, has been found to be associated with greater levels of depression, body image dissatisfaction, and poorer self-esteem in bariatric surgery patients (21).
With few exceptions, weight-related stigma and discrimination have received little empirical attention in the bariatric surgery literature. The present study investigated self-reported stigmatizing experiences among individuals who presented for bariatric surgery, as well as the relationship of these experiences to quality of life and symptoms of depression.
Methods and procedures
Study participants were 117 extremely obese individuals who sought bariatric surgery at the Hospital of the University of Pennsylvania between June 2007 and September 2007.
Approximately 4 weeks before surgery, candidates were required to complete a psychosocial/behavioral evaluation to assess their appropriateness for surgery (15). Before arriving for their evaluation, patients completed the Weight and Lifestyle Inventory (22), which provided information on ethnicity, employment status, education, and self-reported height. At the evaluation, weight was measured with a digital scale, while participants wore shoes and light street clothing. Of 147 persons who were approached to participate in the present study, 117 (80%) agreed to complete the additional measures described below. The study was approved by the Institutional Review Board of the University of Pennsylvania.
Stigma Situations Questionnaire. This self-report questionnaire asked respondents to indicate how often they encountered each of 50 stigmatization experiences frequently related to obesity (20). These experiences of stigma comprise the following 11 scales: Comments from Children (4 items, e.g., “As an adult, having a child make fun of you”); Negative Assumptions by Others (3 items, e.g., “Other people having low expectations of you because of your weight”); Physical Barriers (7 items, e.g., “Not being able to find clothes that fit”); Being Stared at (5 items, e.g., “Being stared at in public”); Inappropriate Comments from Doctors (4 items, e.g., “Having a doctor make cruel remarks, ridicule you, or call you names”); Nasty Comments from Others (11 items, e.g., “Overhearing other people making rude remarks about you in public); Nasty Comments from Family (7 items, e.g., “A spouse/partner calling you names because of your weight”); Being Excluded, Avoided or Ignored (2 items, e.g., “Being unable to get a date because of your size”); Loved Ones Embarrassed by your Size (3 items, e.g., “Having a spouse or partner be ashamed to admit being with you”); Job Discrimination (3 items, e.g., “Losing a job because of your size); and Being Physically Attacked (1 item, i.e. “Being hit, beaten up, or physically attacked because of your weight”). Participants responded to these items using a 10-point scale with the following values: 0 = Never; 1 = Once in your life; 2 = Several times in your life; 3 = About once per year; 4 = Several times per year; 5 = About once a month; 6 = Several times per month; 7 = About once per week; 8 = Several times per week; and 9 = Daily. Total Stigma Situations was calculated by finding the average score of the 50 experiences (20).
Impact of Weight on Quality of Life (IWQOL)-Lite. This 31-item measure assessed weight-related quality of life (23). Using a 5-point Likert scale which ranged from 1 “Never True” to 5 “Always True,” participants responded to items beginning with the phrase “Because of my weight…” The measure provides a total score as well as scores for five specific domains: Physical Functioning (concerns with mobility and day-to-day physical functioning); Self-esteem (concerns related to weight); Sexual Life (sexual limitations related to obesity); Public Distress (fitting into public places and negative reactions from others); and Work (concerns with work performance as it relates to weight). Domain scores were obtained by adding the corresponding item scores; the total score was obtained by adding the domain scores. Higher scores indicate a poorer quality of life.
Beck Depression Inventory-II. Symptoms of depression were measured with the Beck Depression Inventory-II (24), the most widely used measure of depressive symptomatology in bariatric surgery evaluations (25). Scores can range from 0 to 63 with higher scores representing greater depressive symptoms.
Demographic and descriptive variables are presented in Table 1. Participants had a mean age of 46.7 ± 23.3 years, weight of 136.4 ± 26.0 kg, BMI of 48.2 ± 7.5 kg/m2. Sixty-eight percent were white, 26.5% were African American, and the remaining participants were of other ethnic origins. Participants reported 14.2 ± 2.9 years of education and the majority (79.5%) was female. Less than half (39.3%) reported being married, 34.5% were never married, and the remainder were separated, divorced, or widowed. The majority (78.6%) was employed; 17.1% were unemployed or retired, and 4.3% were on disability.
Table 1. . Participant characteristics
Self-reported experiences of stigmatization, weight-related quality of life and depressive symptoms are presented in Table 2. In general, bariatric surgery candidates reported few experiences with stigmatization. The events with the highest mean scores were Comments from Children (1.9 ± 1.6), Negative Assumptions by Others (1.8 ± 1.7), and Physical Barriers (1.7 ± 1.6). These mean values correspond to approximate occurrences of “several times in your life” for each of these events. IWQOL-Lite scores were quite comparable to those reported by other individuals with a BMI ≥40 kg/m2 (23). The mean Beck Depression Inventory-II score corresponded to minimal symptoms of depression (26).
Table 2. . Means ± s.d. for self-reported stigmatization, IWQOL-Lite, and BDI
Correlations among BMI, stigmatization, weight-related quality of life and depressive symptoms are presented in Table 3. BMI was unrelated to total experiences with stigmatization (r = 0.16, P = 0.12) and depressive symptoms (r = 0.16, P = 0.12), but was significantly associated with lower quality of life, as assessed by the total score of the IWQOL-Lite (r = 0.41, P < 0.01).
Table 3. . Correlations among BMI, stigmatization, quality of life and depressive symptoms
Certain types of stigmatization, however, were positively associated with BMI (Table 4). These included including Being Stared at (r = 0.43, P < 0.001), Comments from Children (r = 0.36, P < 0.001), Physical Barriers (r = 0.45, P < 0.001), and Loved Ones Embarrassed by your Size (r = 0.26, P < 0.01).
Table 4. . Correlation of BMI with specific experiences of discrimination
Men and women did not differ in their total, self-reported experiences with stigmatization, t(95) = 0.69, P = 0.49. Additionally, white and non-white participants also did not differ in total, self-reported experiences with stigmatization, t(95) = −1.31, P = 0.19.
The total self-reported experiences with stigmatization were associated with overall weight-related quality of life, r = 0.34, P < 0.01 as well as depressive symptoms, r = 0.31, P < 0.01. Thus, individuals who reported more weight-related stigmatization reported lower weight-related quality of life and more symptoms of depression. More specifically, participants who reported more frequent experiences with stigma had poorer weight- related quality of life in each of the IWQOL-Lite's five domains: Physical Functioning (r = 0.26, P < 0.01); Self-Esteem (r = 4.8, P < 0.001); Sexual Life (r = 0.28, P < 0.01); Public Distress (r = 0.52, P < 0.001); and Work (r = 0.42, P < 0.001).
To investigate the relationship between weight-related stigmatization and depressive symptoms, we grouped patients as experiencing “Minimal” (scores from 0 to 13); “Mild” (scores from 14 to 19); “Moderate” (scores from 20 to 28); and “Severe” depressive symptoms (scores from 29 to 63) (ref. 26). Most of the participants (N = 84, 73.0%) were categorized as having minimal symptoms of depression; 16 (13.9%) had mild symptoms, 9 (7.8%) had moderate symptoms, and 6 (5.2%) were categorized as having severe symptoms of depression. Individuals who reported mild, moderate or severe depressive symptoms (N = 31) reported significantly more frequent comments from children based on their weight (2.4 ± 1.8 vs. 1.6 ± 1.4; t(110) = 2.44, P < 0.05) as compared to those who endorsed minimal symptoms of depression. Those who reported more mild, moderate or severe depressive symptoms, as compared to those who reported minimal depressive symptoms, reported significantly poorer overall weight-related quality of life (106.2 ± 24.2 vs. 82.4 ± 22.2, t(82) = 4.22, P < 0.001) as well poorer quality of life on the IWQOL-Lite Self-Esteem (24.2 ± 7.0 vs. 19.7 ± 6.9, t(111) = 3.1, P < 0.01), Sexual Life (12.5 ± 4.9 vs. 8.7 ± 4.8, t(100) = 3.56, P < 0.001), and Work subscales (10.9 ± 4.0 vs. 7.8 ± 3.5, t(94) = 3.7, P < 0.001). The two groups did not differ on the Public Distress and Physical Functioning subscales.
This is one of first studies to assess self-reported stigmatization among extremely obese individuals who present for bariatric surgery. In general, these individuals reported very little weight-related stigma, with the most common form of stigma being experienced “several times” in participants’ lives. Some specific forms of stigmatization appear to be related to BMI. The occurrence of stigmatization also appears to be associated with poorer weight-related quality of life and greater symptoms of depression.
As overweight and obese individuals now make up the majority of the American population (27), it is possible that the experience of being obese does not engender the same degree of stigmatization as it may have even a decade ago. Intuitively, it is easy to imagine that the social stigma of obesity would be reserved for those with extreme obesity. However, such intuition was not supported by the present study, as the occurrence of weight-related stigma, in general, was not associated with BMI. Although individuals with extreme obesity still account for only 5% of the American population (27), the number of individuals with extreme obesity is increasing at an even greater rate than the number of individuals with a BMI >30 (ref. 28). Perhaps the growing prevalence of extreme obesity, coupled with the media exposure associated with bariatric surgery, has “destigmatized” extremely obese individuals, to a certain extent. Further, the increasing availability and acceptability of bariatric surgery suggests that there may be greater heterogeneity among bariatric surgery samples than a decade ago, when the Stigma Situations Questionnaire was developed. The average patient seeking surgery today, when ∼200,000 procedures are estimated to be performed in the United States, may be less distressed than the typical patient who had surgery a decade ago, when fewer than 20,000 procedures were performed each year (3).
The finding of relatively low levels of stigmatization in bariatric surgery patients is consistent with a 2004 study by Anderson and Wadden (29), which found that only 13% of surgery candidates reported that they were usually or always treated disrespectfully by members of the medical profession because of their weight. A similar study by Rand and Macgregor, published in 1990 (ref. 30), had found that 78% of surgery candidates felt that they were usually or always treated disrespectfully by doctors. The discrepancy between the two studies suggests that weight-related stigmatization in medical settings may have declined as more has been learned about the genetic and neuroendocrine regulation of body weight.
The occurrence of weight-related stigma was associated with lower levels of weight-related quality of life as well as greater depressive symptoms. We note, however, that causal relationships cannot be inferred from our findings. It is certainly possible that stigmatization impedes quality of life and increases one's vulnerability to depression. It is equally plausible that a confounding variable (e.g., generalized negative affect) accounts for endorsement of depressive symptoms, impairments in quality of life, and stigmatization. Longitudinal data with frequent assessments would be needed to determine whether the experience of stigma is responsible for an increase in depressive symptoms or a decrease in quality of life. Additionally, diagnostic interviews are preferable to self-report instruments of depressive symptomatology, as the latter may overestimate depression because of endorsement of somatic symptoms that are common in extremely obese individuals (31).
Currently, <5% of extremely obese individuals present for bariatric surgery. To better understand whether the experience of weight-related stigma is associated with extreme obesity or limited to patients seeking bariatric surgery, future studies would benefit from including a wider range of patient weights as well as including obese individuals who are not seeking surgery. Additionally, future investigations may benefit from exploring other psychological variables, such as self-esteem, body image and social anxiety, which may be associated with weight-related stigma.
Despite the limitations of this study, our findings are notable for the relatively low endorsement of stigmatizing situations. Additionally, findings from the correlational analyses indicate that the perception of weight-related stigma is associated with other unfavorable psychological outcomes, including depressive symptoms and poorer quality of life. Although our methodology precludes statements about causality, we propose that it may be useful to ask candidates for bariatric surgery, during their preoperative psychological evaluations, whether they have experienced weight-related stigma and the event's perceived impact on their current psychosocial status.
D.B.S. has received consulting fees from Ethicon Endo-Surgery. All the other authors have declared no conflict of interests.
This study was supported, in part, by funding from the National Institute of Health (Grants K23-DK060023 and R01-DK072452 to D.B.S., Grant R01-DK069652 to T.A.W., and Grant K23 DK070777 to A.N.F.).