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- Methods and procedures
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.
- Top of page
- Methods and procedures
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.