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Abstract

  1. Top of page
  2. Abstract
  3. Methods and procedures
  4. Results
  5. Discussion
  6. Disclosure
  7. Acknowledgments
  8. References

Objective: This study evaluated the association between experiences of weight-based stigmatization (e.g., job discrimination, inappropriate comments from physicians) within the past month, psychological functioning, and binge eating among a sample of individuals seeking weight loss surgery.

Methods and Procedure: Ninety-four obese adults (25 males and 69 females) seeking weight loss surgery underwent a diagnostic clinical interview and completed a battery of self-report questionnaires measuring experiences of weight-related stigmatization, psychological adjustment, and binge eating behavior.

Results: Weight-based stigmatization was a common experience within the past month among participants. Frequency of stigmatizing experiences was negatively associated with self-esteem and positively associated with depression, anxiety, body image disturbance, and emotional eating. Recent experiences of stigmatization were associated with a diagnosis of binge eating disorder.

Discussion: Weight-based stigmatization is a common experience among obese individuals seeking weight loss surgery, and these experiences are associated with deleterious consequences. It appears that environmental barriers (e.g., chairs too small, not being able to find medical equipment in an appropriate size) and interpersonal attacks are the most common stigmatizing experiences. These data justify future studies to better understand causal relationships and efforts to design and test interventions aimed at reducing weight-based stigmatization and the associated negative consequences.

Since the 1960s research has documented the pervasive and deleterious effects of weight-based stigmatization (1,2,3,4,5,6,7,8,9). Attention to this topic has increased as weight bias has intensified (10) and the rates of overweight and obesity have risen (11). Historically, research has focused on weight bias from the perspective of the nonoverweight person (i.e., how society treats overweight individuals), and observational and laboratory studies consistently have shown that society in general has negative expectations and anti-fat beliefs about overweight and obese individuals (see ref. 3 for review). Less is known about how overweight individuals perceive these biases or how these biases effect well-being and behavior.

A few studies have evaluated weight-based stigmatization from the perspective of the overweight individual. This research has shown that the experience of weight-related stigmatization is associated with negative psychological (e.g., depression, anxiety) and behavioral (e.g., binge eating) consequences (1,2,4), and these findings support current theories of binge eating. For example, binge eating behavior, in part, may be triggered by negative mood states such as anger, anxiety, or depression. This has been described as “dysfunctional mood modulatory behavior” (12). That is, overeating behavior may serve to buffer negative mood by distracting from the mood state directly or interfering with cognitions responsible for the negative mood state. This process has been described as the “escape theory” of binge eating (13) and results in negatively reinforcing the eating behaviors.

Taken together, current theories of binge eating and data demonstrating the association between stigmatization and mental health functioning suggest that negative events such as stigmatizing experiences may be associated with psychological distress and binge eating behavior. However, a major weakness among published stigmatization studies is that they have investigated lifetime experiences of stigmatization as it relates to current psychological functioning and behavior. No study to our knowledge has investigated the association between recent or current experiences of stigmatization and current functioning. Thus, the purpose of this study was to: (i) investigate the frequency and types of recent experiences of weight-related stigmatization (i.e., within the past month) and (ii) evaluate the psychological and behavioral correlates of recent weight stigmatization. It was hypothesized that more frequent stigmatizing experiences within the past month would be associated with current psychological functioning including increases in depression, anxiety, body image disturbance, and binge eating behavior, as well as lower self-esteem.

Methods and procedures

  1. Top of page
  2. Abstract
  3. Methods and procedures
  4. Results
  5. Discussion
  6. Disclosure
  7. Acknowledgments
  8. References

Participants

This study was approved by the Duke University Medical Center Institutional Review Board for research on human participants. All participants completed a battery of standardized questionnaires and a semi-structured clinical interview as part of their assessment for weight loss surgery. The clinical interviews were conducted by licensed clinical psychologists specializing in obesity or a supervised doctoral level clinical psychology intern. A nursing assistant measured height on a standard wall height measuring device and measured weight on a Tanita digital computerized platform scale.

Participants included 94 applicants (25 men and 69 women) who were undergoing a comprehensive evaluation for weight loss surgery at a university based surgical program. Eighty-one percent of the sample was white, 16% were African American, 1% was Latino, and 2% classified themselves as “other.” Thirty-eight percent of the sample reported a childhood onset of obesity, 20% reported adolescent onset of obesity, and 42% reported adult onset. Thirty-four percent had a college degree. Twenty-eight percent of the sample was single, 57% were married, 2% were separated, 12% were divorced and 1% was widowed.

Measures

Stigmatizing Situations Inventory (SSI). Weight-based stigmatization was measured with a modified version of the Stigmatizing Situations Inventory (4). The SSI assesses the frequency in which respondents have experienced stigmatizing situations. Eleven stigma categories (e.g., nasty comments from others, job discrimination, inappropriate comments from doctors) are embedded within the measure. A total or aggregate stigmatizing experience score reflects the mean of all questions. Directions for this scale were modified from asking participants to indicate lifetime experiences to how often they experienced stigmatizing situations within the past month. Items in the original measure are rated on a 10-point Likert scale, but previous research suggests that respondents have difficulty estimating the frequency of specific stigmatizing experiences using the original 10-point scale (14,15). Thus, the 10-point Likert scale was modified to six-points ranging from zero (never) to five (daily) for the current study. Additionally, two questions asking about childhood experiences were not coded. Internal consistency of the original measure was high (i.e., an overall α of 0.95; ref. 4). The current modified version had an overall α of 0.92 indicating sufficient reliability (16). As in the original measure, the α-coefficients varied widely for the subscales (see Table 2).

Table 2. . Descriptive Statistics for the Stigmatization Situation-Specific Scales
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Beck Depression Inventory. The Beck Depression Inventory is a widely used 21-item self-report inventory designed to assess symptoms suggestive of depression. The scale evaluates the presence and severity of affective, cognitive, motivational, vegetative, and psychomotor components of depression within the last 7 days. Increased scores indicate more depressive symptoms (17).

Rosenberg self-esteem scale. The Rosenberg self-esteem scale assesses global self-esteem and contains 10-point Likert scale items ranging from strongly agree to strongly disagree. The scale is a unidimensional measure of global self-esteem. Increased scores indicated greater self-esteem (18).

Binge eating scale (BES). Uncontrolled eating and other overeating behaviors reflective of binge eating were measured with the BES (19). This 16-item scale assesses both the behavioral manifestations of binge eating (e.g., eating large amounts of food) as well as the feelings and cognitions surrounding emotional and uncontrolled overeating episodes (e.g., guilt, fear of being unable to stop eating). Higher scores suggest a greater degree of binge eating severity. Typically, scores >27 indicate severe binge eating behavior and scores <17 indicate the absence of binge eating behavior (20). Of note, the BES was not used as a diagnostic tool in this study.

Symptoms checklist-90-R (SCL-90-R). The SCL-90-R is a 90-item self-report multidimensional questionnaire designed to assess a broad range of psychiatric symptoms experienced within the past 7 days (21). There are nine primary dimensions, three of which where used in this study: depression, anxiety, and phobic anxiety. Phobic anxiety measures anxiety toward travel, public places, and crowds. These three subscales were used based on theoretical relevance and previous findings in the literature (1,2,3). Elevated t-scores are interpreted to suggest psychological distress in that domain.

Body shape questionnaire. The body shape questionnaire is a 34-item questionnaire that assesses body image disturbance within the last 4 weeks (22). It has been widely used among obese populations (23,24,25). Higher scores indicate increased body image distress (22).

Semi-structured interview. The semi-structured clinical interviews were conducted by licensed psychologists or a supervised doctoral level medical psychology intern and were similar to published weight loss surgery evaluations (26,27). Before the interview, clinicians reviewed results of the questionnaire battery. Psychological diagnoses were made at the end of the interview based on the Diagnostic and Statistical Manual for Mental Disorder 4th edition (DSM-IV-TR (28)). Overall, the psychologist had the benefit of information gathered during the clinical interview as well as from the completed questionnaires to formulate appropriate diagnosis (if any were indicated). During the interview, patients’ weight loss goals and overall expectations for surgery also were assessed.

Results

  1. Top of page
  2. Abstract
  3. Methods and procedures
  4. Results
  5. Discussion
  6. Disclosure
  7. Acknowledgments
  8. References

All analyses were performed using SAS software (version 9.1; SAS Institute, Cary, NC). Calculation of coefficient-α (16) was used to evaluate the reliability of the modified version of the SSI. Means of all subscales of the SSI were computed to determine the frequency in which participants perceived stigmatization experiences. To test the hypothesis that stigmatization was associated with negative psychological and behavioral consequences, a series of hierarchical regressions were conducted when the dependant variables were continuous. Logistic regression models were conducted when dependant variables were dichotomous.

Tables 1 and 2 summarize descriptive statistics for the sample.

Table 1. . Descriptive statistics: means and s.d. for variables of interest
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Stigmatizing experiences and psychological functioning

Stigmatizing experiences. The most frequently experienced stigmatizing situations were encountering physical barriers (e.g., chairs that are too small; M = 0.85, s.d. = 0.86), people making unflattering assumptions about obese people (M = 0.62, s.d. = 1.03), being avoided, excluded, or ignored because of weight (M = 0.54, s.d. = 1.4), and receiving inappropriate comments from physicians (M = 0.53, s.d. = 0.76; see Table 2).

Given the design of the stigmatization response scale (i.e., ordinal level ranging from “never” to “daily”), positive endorsement of the stigmatizing situations independent of frequency was evaluated. That is, how many individuals experienced some form of stigmatizing situation over the past month (see Table 2). Most of the situations (i.e., 6 of 11) were experienced by >50% of the participants. The most common situations included experiencing physical barriers or obstacles (88%), receiving nasty comments from others (72%) having family members make disparaging remarks toward them (65%), and receiving inappropriate remarks from doctors (61%). Believing that their loved ones were embarrassed by their size (54%), others making negative assumptions about obese individuals (50%) and being stared at (46%) were also common experiences. One participant indicated being physically attacked because of weight. BMI was not significantly correlated with the aggregated score of stigmatizing experiences (r = 0.13; P = 0.22). However, two subscales were significantly correlated with BMI including encountering physical barriers (r = 0.25; P = 0.02) and being starred at (r = 0.27; P = 0.007). The frequency of stigmatizing experiences was significantly associated with weight loss goals (r = 0.23, P < 0.03).

Psychological functioning. The means for depression, body image, self-esteem, and subscales of the SCL-90-R were in the mild to nonclinical range (see Table 1).

The association between weight-based stigmatizing experience, psychological functioning, and binge eating behavior. A series of multiple linear regression analyses were used to test whether the frequency of stigmatizing experiences during the past month predicted psychological functioning. All analyses controlled for the effects of age, gender, and BMI. The full regression model (R2) predicting depression as measured by the Beck Depression Inventory was statistically significant (F (4, 89) = 5.35, P = 0.0007) and accounted for nearly 16% of the observed variance in depression scores. More frequent stigmatizing experiences were significantly related to higher depression (b = 0.29, P < 0.004) and uniquely accounted for 8% of the variance in depression after controlling for age, gender, and BMI. Similar results were obtained for self-esteem, body image distress, and depression and anxiety subscales on the SCL-90-R when entered as dependant variables (see Table 3). Thus, greater frequency of stigmatizing experiences during the past month significantly predicted the severity of psychological symptoms. Although BES scores were significantly correlated with stigmatizing experiences (r = 0.26; P = 0.01), when controlling for age, gender, and BMI the overall regression model was not significant (see Table 3).

Table 3. . Regression analyses summary for control variables and stigmatizing experiences predicting mental health
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Psychological diagnosis was assigned based on an integration of information obtained from the clinical interview and questionnaire data. A description of this process is provided in the methods section. Fifteen percent of the sample met criteria for a current depressive disorder, 22% met criteria for an anxiety disorder, and 25% met criteria for binge eating disorder. The association between psychological diagnosis and weight-based stigmatization was investigated using a series of logistic regression models with psychological diagnoses set as the criterion variable. Weight-based stigmatization was not significantly associated with a depression or anxiety disorder diagnosis. However, weight stigmatization was significantly associated with a current diagnosis of binge eating disorder (χ21 = 5.27, P = 0.027); odds ratio = 3.3. An odds ratio approximates the likelihood of the outcome of interest (i.e., diagnosis of BED) being higher in the group exposed to a particular risk factor (i.e., stigma experiences) than in those not exposed to the risk factor. Thus, a 1 s.d. increase on the stigmatization measure increased the odds of having BED by about three times.

Discussion

  1. Top of page
  2. Abstract
  3. Methods and procedures
  4. Results
  5. Discussion
  6. Disclosure
  7. Acknowledgments
  8. References

The main purpose of this study was to address shortcomings of prior research, which focused on lifetime experiences of weight-based stigmatization as they relate to current psychological and behavioral functioning (1,2,3,14). Previous measures of weight-based stigmatization were modified to assess recent experiences (i.e., within the past month). Evaluation of the modified scale using coefficient-α demonstrated sufficient reliability and findings consistent with predicted outcomes based on previous research (e.g., stigma associated with psychological distress) suggest evidence of validity.

The most common stigmatizing situations experienced within the past month among this sample were encountering physical barriers (e.g., not being able to find medical equipment in an appropriate size), people making unflattering assumptions toward the obese individual, being avoided, excluded, ignored because of weight, and receiving inappropriate comments from physicians. Results of regression analyses confirmed the hypothesis that recent stigmatizing experiences were associated with psychological distress (e.g., depression, anxiety, phobic anxiety, lower self-esteem, and body image) as well as binge eating behavior. These findings are consistent with other reports (1,2,4) and provide further evidence of the deleterious effects of weight-based stigma.

Regarding binge eating, we found that a 1 s.d. increase on the stigmatizing questionnaire increased the chances of being diagnosed with binge eating disorder threefold. This stigma binge eating disorder relationship was in contrast to another study that did not find an association between stigma and binge eating diagnosis (14). One potential reason for the equivocal results may be due to the different methods used to assess binge eating (diagnostic interview vs. questionnaire). These discrepancies also may be related to differences in study samples (e.g., weight loss surgery patients vs. an on-line sample recruited through membership in a noncommercial weight loss support group). Nonetheless, our finding is similar to a previous study by Ashmore et al. that found a relation between binge eating severity as measured by the BES and lifetime exposure to stigma (2). This finding is also consistent with current theoretical models of binge eating (12,13). That is, binge eating may be one method to escape from the negative affect caused by stigmatizing experiences.

In the current study, the overall frequency of recent experiences of weight-based stigmatization was not correlated with BMI while the specific experiences of being stared at and encountering barriers were. The lack of association between the aggregate stigma score and BMI is in contrast to previous reports, with the exception of one sample (14), which found a relationship between BMI and lifetime experiences of stigmatization (1,2,4,29). We measured recent experiences of stigma rather than lifetime. Because all participants in this study were significantly overweight during the past month, it is possible they perceived similar amounts of overall stigmatization. However, when evaluating lifetime experiences it is possible that those at higher levels of BMI have been overweight longer and thus exposed to more weight bias over time. It also may be the case that no association was found because of a relatively smaller sample size or a restricted range of BMI in the current study.

One unique finding in this study is the strong relation found between stigma experience and phobic anxiety. Phobic anxiety as measured by the SCL-90-R taps into feeling afraid to travel, feeling uneasy in crowds, feeling self-conscious with others, and having to avoid certain things or places because they are frightening. It is possible that the fear of specific situations was learned and is maintained by repeated exposure to stigmatization.

The findings of this study have important clinical and treatment implications. Individuals seeking weight loss surgery report a considerable amount of weight-related stigmatization, especially from interpersonal sources including health-care professionals. Research has shown strong anti-fat biases among health professionals (30) and that these biases exist even among health-care providers specializing in obesity treatment (31). These attitudes and biases may result not only in negative affect and binge eating but also in avoidance of health-care utilization and delayed care (32,33,34). From a health-care provider perspective, the deleterious effects of stigma may be partially prevented by simply changing how one talks to patients. For instance, according to a recent study, obese treatment-seeking individuals prefer terms such as weight, BMI, and heaviness compared to fatness, obesity and excess fat (35). It may be useful to focus bias reduction efforts toward health-care professionals and students, especially those who will eventually work in clinical settings. From the perspective of the patient, it may be useful to assist overweight and obese individuals to learn more effective ways of coping (e.g., cognitive restructuring) with the social prejudice (4,7,36). Similar strategies have been shown to help individuals improve distress associated with body image disturbance (37).

There are limitations to the current study that should be considered. This study included an obese sample seeking weight loss surgery (mean BMI = 47.8) and a disproportionate number of white females. Nontreatment seeking individuals may not experience the same level of distress associated with recent weight-based stigmatization. It is possible that the effects of weight-based stigmatization would be attenuated among an African-American sample given possible attitude differences toward body shape (38). Thus, these findings may not generalize to individuals seeking weight loss treatment from different demographic and/or ethnic backgrounds or to nontreatment seeking overweight individuals. Additionally, data from this study were correlational. It cannot be concluded that weight-based stigmatization causes psychological distress or binge eating. As Myers and Rosen (4) speculated, the relation could be reversed. Individuals who are psychologically distressed may be more likely to perceive stigmatization associated with weight. Finally, we did not measure or control for lifetime experiences of stigmatization, which may be a potential limitation.

There remain many unanswered questions about the consequences of weight-based stigmatization. Experimental studies are needed to establish casual connections between stigmatization and psychological functioning and/or eating pathology. The direct effects of stigmatizing experiences on psychological functioning, eating behavior, and physiological functioning (e.g., cortisol release, blood pressure) could be tested by laboratory experiments where stigmatizing situations could be simulated. Similar experiments have been conducted to better understand the effects of racism. For instance, African-American participants have been exposed to racist stimuli (e.g., audio tapped racist stressor, racist film clips) to determine the physiological effects of racism (see ref. 39,40). It also would be informative to study which methods of stigma reduction are most effective at reducing weight bias. Future studies investigating both lifetime and recent experiences of weight-based stigmatization may help us better understand the impact of overall exposure to weight-based stigmatization on mental health functioning.

Acknowledgments

  1. Top of page
  2. Abstract
  3. Methods and procedures
  4. Results
  5. Discussion
  6. Disclosure
  7. Acknowledgments
  8. References

No outside funding/support was provided for this study.

References

  1. Top of page
  2. Abstract
  3. Methods and procedures
  4. Results
  5. Discussion
  6. Disclosure
  7. Acknowledgments
  8. References