SEARCH

SEARCH BY CITATION

Abstract

  1. Top of page
  2. Abstract
  3. Methods and Procedures
  4. Results
  5. Discussion
  6. Acknowledgmant
  7. DISCLOSURE
  8. REFERENCES

Depressed mood in severely obese, bariatric surgery–seeking candidates is influenced by obesity stigma, yet the strategies for coping with this stigma are less well understood. This study hypothesized that coping strategies are significantly associated with depressed mood above and beyond demographic factors and frequency of weight-related stigma, with specific coping strategies differing between racial groups. Severely obese, bariatric surgery–seeking adults (N = 234; 91 African Americans) completed the Beck Depression Inventory (BDI) and Stigmatizing Situations Inventory (SSI). Two hierarchical linear regressions were conducted separately for African Americans and whites. For both racial groups, age, sex, BMI, years overweight, annual income, and education level did not account for a significant portion of the variance in BDI scores. The frequency of stigmatizing situations and coping strategies significantly explained 16.4% and 33.2%, respectively, of the variance for whites, and 25.9% and 25%, respectively, for African Americans (P < 0.001). Greater depressed mood in whites was associated with older age, lower education, fewer positive self-statements, and less self-love and more crying; while in African Americans greater depressed mood was associated only with ignoring the situation (P < 0.05). The study found that regardless of race, depressed mood in severely obese, bariatric surgery–seeking clients is related to the frequency of stigmatizing experiences and associated coping strategies. This suggests that efforts to reduce the deleterious effects of weight-related stigma need to focus both on reducing the frequency of stigmatization and on teaching effective coping strategies. These efforts also need to take into account the client's racial background.

Weight-related stigma is widespread (1) and associated with lowered self-esteem and increased depression and body dissatisfaction in overweight individuals (2) and severely obese (BMI >40) bariatric surgery patients (3,4). Severe obesity is the fastest growing obesity category in the United States with bariatric surgeries for this group increasing eightfold from 1998 to 2000 (ref. 5). Compared with other weight-loss treatment patients, bariatric surgery patients appear to have a higher BMI (6,7) and earlier onset of overweight (6). In this group, weight-related stigma is related to depressed mood even when controlling for binge-eating and weight-related physical disability (4); however, it is not clear whether depressed mood is explained more by the frequency of stigmatizing experiences or certain coping strategies.

The few studies on coping with obesity stigma and psychological health (8) report mixed findings. One experiment comparing 58 normal- and overweight women (9) found that self-accepting weight stereotypes resulted in more negative mood. A cross-sectional study of 146 weight-loss-program participants (91.1% white; ref. 10) found no significant correlations between coping strategies and mental health, body-image concerns, or self-esteem when controlling for weight and stigma frequency. In 2,449 women (95% white) seeking weight-loss support (11), the frequency of stigma and coping responses did not significantly explain the variance in self-esteem and depressed mood, but when 222 men and women (87% and 94% white, respectively) were matched on age and BMI, coping responses significantly predicted self-esteem only in women.

Although compared with lower-weight individuals, the severely obese are more likely to experience weight-related stigmatization (2), research on strategies for coping with obesity stigma in this group is lacking. Furthermore, studies on coping with obesity stigma have examined predominantly white samples, despite research suggesting that race affects weight perception: white but not African-American women rate overweight (vs. lower-weight) women lower on attractiveness, intelligence, job and relationship success, happiness, and popularity (12). In contrast, African-American women, compared with African-American men and white men and women, report liking their obese peers more (13).

Therefore, research is needed to examine the psychological effects of coping with obesity stigma in severely obese, bariatric surgery–seeking adults, also considering the effects of race. Understanding this relationship could help inform strategies for reducing the harmful effects of obesity stigma by identifying whether efforts should focus on reducing the incidence of stigma, on enhancing effective coping, or both. To address this gap, we hypothesize that in bariatric surgery–seeking adults, coping is significantly associated with depressed mood above and beyond demographic factors and weight-related stigma frequency, with racial differences for specific coping strategies.

Methods and Procedures

  1. Top of page
  2. Abstract
  3. Methods and Procedures
  4. Results
  5. Discussion
  6. Acknowledgmant
  7. DISCLOSURE
  8. REFERENCES

A consecutive sample of 260 severely obese (BMI: mean (M) ± SD = 49.21 ± 9.00) bariatric surgery–seeking adults was assessed before bariatric surgery at the University of Chicago between July 2007 and August 2010. Informed consent was obtained and questionnaires on demographics, weight stigma, and depressed mood were completed pre-surgery. This study was approved by the University of Chicago institutional review board. Fifty-five percent were white, 35% African American, 9.2% Hispanic, and 0.8% other. Non-white or non-African-American participants were excluded from the analysis, resulting in 234 individuals, with 91 African Americans (78% female) and 143 whites (72% female). The groups did not differ significantly on BMI and education level, but whites reported significantly higher age, income, and time overweight (P < 0.05).

Weight-related stigma and coping were assessed using the Stigmatizing Situations Inventory (SSI; ref. 10), a comprehensive questionnaire assessing the frequency of 50 weight-related stigmatizing experiences (e.g., “As an adult, having a child make fun of you”), and 99 associated coping strategies (e.g., “I tell the other person off.”) Participants were instructed to report the frequency of coping strategies in response to stigmatizing situations (“Please indicate whether, and how often, you have used each of the following strategies to cope with the sorts of situations listed above.”) As in previously published research (11), responses were rated on a four-point Likert scale from 0 (never) to 3 (multiple times). An overall mean score was computed for stigma frequency (10) with high internal consistency (α = 0.94). Twenty-one coping subscales were also computed (10), with high internal consistency of the overall coping responses questionnaire (α = 0.94) and most subscales having acceptable or good internal consistency, though several subscales with fewer items had lower α values, consistent with previous research using this measure (10,11). Only coping subscales, not a total score, were used in the regression analyses.

Depressed mood was measured using the Beck Depression Inventory-II (BDI; ref. 14) total score, a 21-item questionnaire with high validity and reliability, where higher scores indicate greater symptom severity.

Results

  1. Top of page
  2. Abstract
  3. Methods and Procedures
  4. Results
  5. Discussion
  6. Acknowledgmant
  7. DISCLOSURE
  8. REFERENCES

t-Tests were conducted between racial groups for the SSI score and each of the 21 SSI coping subscales. Whites compared with African Americans reported a significantly lower frequency of using faith (t[232] = 4.59, P < 0.001; M ± SD = 1.53 ± 0.92, M ± SD = 2.06 ± 0.82), self-love (t[232] = 2.67, P < 0.01; M ± SD = 1.61 ± 0.82; M ± SD = 1.88 ± 0.71), and negative responses (t[232] = 2.54; M ± SD = 0.5 ± 0.48; M ± SD = 0.71 ± 0.67) and increased frequency of using negative self-talk (t[232] = −2.04, P < 0.05; M ± SD = 1.22 ± 0.78; M ± SD = 0.99 ± 0.87), refusing to diet (t[232] = −2.43, P < 0.05; M ± SD = 1.23 ± 0.59; M ± SD = 1.05 ± 0.54), ignoring the situation (t[232] = −2.87, P < 0.01; M ± SD = 1.45 ± 0.75; M ± SD = 1.16 ± 0.75), and seeking therapy (t[232] = −2.87, P < 0.01; M ± SD = 0.66 ± 1.01; M ± SD = 0.34 ± 0.69).

The SSI coping subscales that significantly correlated with BDI scores for each racial group were entered in a hierarchical linear regression conducted separately for each race (Table 1). BDI was entered as the dependent variable, controlling for age, sex, BMI, years overweight, income, and education level in the first step, stigmatizing situations frequency in the second, and coping subscales in the third.

Table 1.  Regressions for African Americans and whites examining the association between stigmatizing situations and coping with depressed mood controlling for other demographic variables
inline image

SSI coping subscales significantly explained 33.2% of the variance in BDI scores for whites, and 25% for African Americans, above and beyond demographic variables and frequency of stigmatizing situations (P < 0.001). Frequency of stigmatizing situations further accounted for 16.4% of the variance in whites and 25.9% in African Americans (P < 0.001). Greater depressed mood in whites was associated with older age (β = 0.162, P = 0.045), lower education (β = −0.193, P = 0.008), fewer positive self-statements (β = −0.229, P = 0.043) and instances of self-love (β = −0.227, P = 0.006), and more frequent crying (β = 0.385, P < 0.001); while in African Americans, more frequently ignoring the situation was the only significant variable associated with greater depressed mood (β = 0.245, P = 0.039).

Discussion

  1. Top of page
  2. Abstract
  3. Methods and Procedures
  4. Results
  5. Discussion
  6. Acknowledgmant
  7. DISCLOSURE
  8. REFERENCES

This study is the first to examine racial differences in depressed mood and coping with obesity stigma in a sample of severely obese, surgery-seeking adults. The frequency of using certain strategies to cope with stigmatizing experiences was significantly associated with depressed mood in African Americans and whites, above and beyond demographic factors and frequency of weight-related stigma. Furthermore, African Americans and whites differed in the type of coping strategies associated with depressed mood.

Replicating previous findings (4) this study provides evidence linking weight-related stigma and depressed mood in severely obese, surgery-seeking adults, and adds to the literature that this relationship exists both for whites and for African Americans, despite research suggesting that African Americans, particularly women, may be more accepting of overweight (12,13). This study also found that older age and more frequent crying in response to weight-related stigma are related to depressed mood in whites, while African Americans are more likely to be depressed if they cope with obesity stigma by ignoring the situation.

Although several protective coping strategies emerged for whites, namely positive self-statements (e.g., challenging negative thoughts about oneself) and self-love (e.g., loving oneself even when it seems like others do not), it is of concern that no protective factors emerged for African Americans. Research on coping with racial discrimination in African-American women (15) suggests that depressive symptoms are positively associated with avoidant coping and negatively associated with problem-focused coping, yet similar relationships were not found in this study of obesity stigma. These different findings may have resulted from limitations in our measure of coping with obesity stigma or from different coping strategies being used for different forms of stigma. This warrants further investigation into coping with obesity stigma in African Americans with severe obesity.

These results should be considered in conjunction with some limitations. Although currently the most comprehensive measure for assessing obesity stigma, the SSI was designed and validated on a predominantly white sample, possibly limiting its applicability to African Americans. Additionally, it does not measure individual differences in stigma consciousness, which could affect the subjective experience of weight-stigma frequency, nor does it differentiate between coping with the situation or the emotion resulting from the stigmatizing situation. Furthermore, the results may be driven by the larger group of women in the sample, and a gender-balanced sample is needed to identify race and gender interactions and differences when coping with obesity stigma. Due to the cross-sectional study design, causal inferences on the impact of obesity stigma on depressed mood cannot be drawn but this may be examined in future experimental studies.

The findings from this study stress the importance of efforts to eliminate weight-related stigma by reducing the number of stigmatizing experiences and also teaching effective coping strategies. Bariatric surgery–seeking whites may benefit from strategies that increase a positive attitude toward oneself, while African Americans may benefit from strategies that reduce ignoring and avoidance of stigmatizing situations. Although it can be speculated that a more problem-solving coping approach may be beneficial for African Americans, further research is needed to identify effective strategies for this population.

Acknowledgmant

  1. Top of page
  2. Abstract
  3. Methods and Procedures
  4. Results
  5. Discussion
  6. Acknowledgmant
  7. DISCLOSURE
  8. REFERENCES

E.Y.C. acknowledges the support of NARSAD, the Mental Health Foundation, the American Foundation of Suicide Prevention on Young Investigator grants, and the National Institute of Mental Health (5K23MH081030-03; 1R34MH083914-01A2).

REFERENCES

  1. Top of page
  2. Abstract
  3. Methods and Procedures
  4. Results
  5. Discussion
  6. Acknowledgmant
  7. DISCLOSURE
  8. REFERENCES