Body image and psychosocial differences among stable average weight, currently overweight, and formerly overweight women: the role of stigmatizing experiences
Introduction
Obesity has become one of the greatest health epidemics in the world (Björntorp, 2002; Wadden et al., 2002, Wadden et al., 2002; World Health Organization, 1998). Among adults in the United States, the age-adjusted rates of obesity (body mass index≥30.0 kg/m2) based on the 1999–2000 NHANES data were 34.0% for women and 27.7% for men, and with the inclusion of overweight persons (body mass index=25.0–29.9), these rates climb to 62.0 and 67.0%, respectively (Flegal, Carroll, Ogden, & Johnson, 2002). During this same period, among children ages 6–11 years, 16.0% of boys and 14.5% of girls were overweight, and among adolescents ages 12–19, 15.5% of both boys and girls were overweight (Ogden, Flegal, Carroll, & Johnson, 2002). These rates reflect significant increases in the prevalence of overweight or obesity relative to the NHANES data from 1988 to 1994.
In view of Western society’s exacting standards of physical appearance and its discriminatory “anti-fat” attitudes and behaviors, it should be no surprise that obese individuals experience psychosocial consequences of their weight. Friedman and Brownell’s (1995) meta-analysis on the psychological correlates of obesity found few identifiable differences between obese and nonobese persons. They argued, however, that prior research has often compared two very heterogeneous populations (obese and nonobese), examined only obese persons seeking weight loss, used limited measures, or lacked appropriate controls. Therefore, the conclusion of no psychosocial differences between obese and nonobese individuals may be premature (Wadden et al., 2002, Wadden et al., 2002). Friedman and Brownell, 1995, Friedman and Brownell, 2002 have concluded that obesity might cause major psychological difficulties for some individuals, mild problems in some, and perhaps no distress in others.
One of the most reliable psychological correlates of overweight and obesity is body dissatisfaction (Cash & Roy, 1999; Friedman & Brownell, 1995; Sarwer, Wadden, & Foster, 1998; Schwartz and Brownell, 2002, Schwartz and Brownell, 2004). If an individual’s social environment regards her or him as unattractive, it should not be surprising that the obese individual will internalize this self-view. Although obese individuals may or may not be more likely to distort their body size (Schwartz & Brownell, 2004), they are more dissatisfied with their appearance and are more avoidant of social situations in comparison to nonobese people (Rosen, 2002, Sarwer et al., 1998; Schwartz & Brownell, 2004). Within the overweight and obese population, as well as within the general public, women are more likely to express body dissatisfaction and distress than their male counterparts (Cash & Roy, 1999; Schwartz and Brownell, 2002, Schwartz and Brownell, 2004). A negative body image can have adverse psychosocial consequences, including disordered eating (Cash & Deagle, 1997; Stice, 2002), depression (Noles, Cash, & Winstead, 1985), social anxiety (Cash & Fleming, 2002a), impaired sexual functioning (Wiederman, 2002), and poor self-esteem (Powell & Hendricks, 1999). Cash and Fleming (2002b) and Cash, Jakatdar, and Williams (in press) found an inverse relationship between women’s body mass and body image quality of life, which refers to the impact of body image on daily life experiences. This relationship remained even after body dissatisfaction was statistically controlled.
A number of risk factors contribute to, or are associated with, body image dissatisfaction and distress in overweight or obese individuals. Binge eating disorder (BED) has been identified as a correlate, not only of body image problems, but also of a number of psychosocial difficulties among the obese (Mussell et al., 1996). Overall, findings suggest that individuals who binge, regardless of their weight, reveal significantly greater psychological distress on standard measures of psychopathology, have a more negative body image, lower levels of self-esteem, and a higher lifetime prevalence of psychiatric illness, particularly affective disorders (Bartlett, Wadden, & Vogt, 1996; Berman, Berman, Heymsfield, & Fauci, 1992; French, Jeffery, Sherwood, & Neumark-Sztainer, 1999; Webber, 1994). Although the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR; American Psychiatric Association, 2000) does not include body image disturbance as a criterion for BED, researchers argue that significantly elevated levels of dysfunctional body image attitudes regarding weight and shape are a major characteristic of the disorder (Cargill, Clark, Pera, Niaura, & Abrams, 1999; Grilo, 2002). It appears, therefore, that body image and binge eating are associated.
A second possible risk factor for increased body dissatisfaction in obese individuals is the stigma and discrimination that they experience in their daily lives (Neumark-Sztainer & Haines, 2004). As the rates of overweight and obesity in the United States are rapidly increasing, Western society perpetuates messages that being thin means being beautiful and successful in many areas of life (Jackson, 2002, Tiggemann, 2002). In contrast, being overweight connotes ugliness, morbidity, laziness, and personal failing (Puhl and Brownell, 2001, Puhl and Brownell, 2002). Such negative attitudes have come to be “one of the last socially acceptable forms of discrimination” (Puhl & Brownell, 2002, p. 108). Stigma and discrimination can be found in a wide range of life domains, including employment (Pingitore, Dugoni, Tindale, & Spring, 1994; Roehling, 1999), medical and health care (Foster et al., 2002; Harvey & Hill, 2001; Hebl & Xu, 2001; Price, Desmond, Krol, Snyder, & O’Connell, 1987), and formation of relationships in childhood (Anesbury and Tiggemann, 2000, Bell and Morgan, 2000, Cramer and Steinwart, 1998). Prejudice against obese individuals begins at a young age and lasts throughout the lifespan. For instance, Cramer and Steinwart (1998) found that preschool children endorsed a negative stereotype about fat persons, and that as children grow older their negative beliefs strengthen. College students have described obese people as more self-indulgent, less self-disciplined, and less attractive than average weight individuals (Lewis, Cash, Jacobi, & Bubb-Lewis, 1997), stereotypes that tend to be shared by overweight persons themselves (Lewis et al., 1997; Tiggemann & Rothblum, 1988).
Some overweight or obese individuals face difficulties in their abilities to function in interpersonal situations. Recreational activities may be constrained due to physical discomfort or social rejection (Lean, Han, & Seidell, 1999; Myers & Rosen, 1999). Although Berman et al. (1992) found that a significant number of treatment-seeking obese individuals were limited or isolated in their social relationships, Miller, Rothblum, Brand, and Felicio (1995) discovered that obese and nonobese women did not differ in social competence, social network size, or perceived social support from friends and family. Obesity may reduce opportunities for dating and marriage, especially among women (Gortmaker, Must, Perrin, Sobol, & Deitz, 1993; Stake & Laurer, 1987). Finally, Cash, Beskin, and Yamamiya (2001) found that weight was modestly positively related to physical self-consciousness during sex among college women.
Quality of life seems to improve after weight loss, including an increase in social and physical activities (Isacsson, Frederiksen, Nilsson, & Hedenbro, 1997), better relationships with others, including spouses (Chandarana, Conlon, Holliday, & Deslippe, 1990), better body image (Cash, 1994; Foster, Wadden, & Vogt, 1997), and improved sexual functioning (Chandarana et al., 1990). Although these findings suggest that quality of life may be impaired in overweight or obese persons, studies are based on clinical samples seeking weight loss, are sometimes retrospective, and are far from comprehensive in tapping all facets of quality of life.
While weight loss may lead to increased body satisfaction, some formerly overweight persons may also experience “phantom fat”, whereby they remain weight-concerned and retain some degree of body dissatisfaction despite weight loss (Adami et al., 1998; Adami, Meneghelli, Bressani, & Scopinaro, 1999; Cash, Counts, & Huffine, 1990). Formerly, overweight individuals’ greater body image concerns compared to weight-matched, never-overweight individuals evinces this phenomenon. On the other hand, some research has not confirmed phantom fat, such that formerly overweight individuals reported body satisfaction equivalent to average-weight controls (Cash, 1994, Foster et al., 1997). The current study reexamines this issue.
The purpose of this research was to examine and compare body image and psychosocial functioning among three groups of women. Only women were studied given the evidence that, relative to men, they are at greater risk for psychosocial difficulties when overweight (Cash & Roy, 1999; Friedman & Brownell, 1995). Three nonclinical cohorts were studied: (a) now overweight (NOW) individuals, defined as women who have been overweight for at least the past 3 years; (b) formerly overweight (FOW) individuals, who were overweight at some time in their life for at least 6 months, excluding pregnancy, and have been average weight for the past 2 or more years; and (c) stable average weight (SAW) individuals, who have maintained an average weight throughout their lifetime. These groups were assessed on dimensions of body image, self-esteem, social anxiety, depression, eating behaviors, quality of life, and perceived weight-related stigmatization. We sought to answer these empirical questions: Do SAW and FOW women report significantly better body image, self-esteem, eating behaviors, affect, and quality of life compared to women who are currently overweight (NOW)? Furthermore, to examine the phantom fat phenomenon, what are the differences between weight-matched SAW and FOW women? Finally, among NOW and FOW women, is weight-related stigmatization associated with current body image and psychosocial functioning?
Section snippets
Participants and recruitment
The sample consisted of 165 women from community (n=65) and university populations (n=100), both from the mid-Atlantic region of the United States. Participants were 18 years of age or older. College participants responded to announcements posted on the campus, and community participants responded to flyers posted at local exercise facilities and advertisements in local print media and on the internet. The latter was posted on a Weight Watchers website, which produced only five participants.
Preliminary analyses
Prior to performing inferential analyses, we examined whether their assumptions were met. All dependent variables were normally distributed. The assumption of homogeneity of variance was slightly violated in a few analyses; however, analysis of variance (ANOVA) is robust to this violation if there are no outliers and sample sizes are relatively large and equal (Tabachnick & Fidell, 2001). Post-hoc Tukey HSD tests were performed if the overall ANOVA for the group comparisons for each scale was
Discussion
Excessive weight can lead to increased risk of a variety of medical conditions, ranging from diabetes mellitus to cardiovascular disease (Pi-Sunyer, 2002). Yet it is obesity’s potential psychosocial consequences and vulnerabilities that are less understood. These vulnerabilities stem from numerous risk factors, including the stigma associated with overweight and obesity (Cash and Roy, 1999, Puhl and Brownell, 2001, Puhl and Brownell, 2002). To evaluate the nature and scope of psychosocial
References (80)
Body image and weight changes in a multisite, comprehensive very-low-calorie diet program
Behavior Therapy
(1994)- et al.
Thin is good, fat is bad: How early does it begin?
Journal of Applied Developmental Psychology
(1998) - et al.
Medical students’ readiness to provide lifestyle counseling for overweight patients
Eating Behaviors
(2002) - et al.
The assessment of binge eating severity among obese persons
Addictive Behaviors
(1982) - et al.
Family practice physicians’ beliefs attitudes, and practices regarding obesity
American Journal of Preventive Medicine
(1987) - et al.
Cognitive behavior therapy for negative body image in obese women
Behavior Therapy
(1995) - et al.
Obesity and body image
Body Image: An International Journal of Research
(2004) - et al.
Body image and body weight in obese patients
International Journal of Eating Disorders
(1998) - Adami, G. F., Meneghelli, A., Bressani, A., & Scopinaro. (1999). Body image in obese patients before and after stable...
- et al.
The extended satisfaction with life scale: Development and psychometric properties
Social Indicators Research
(1996)
An attempt to reduce negative stereotyping of obesity in children by changing controllability beliefs
Health Education Research
Psychosocial consequences of weight cycling
Journal of Consulting and Clinical Psychology
Children’s attitudes and behavioral intentions toward a peer presented as obese: Does a medical explanation for the obesity make a difference?
Journal of Pediatric Psychology
The incidence and comorbidity of psychiatric disorders in obesity
Journal of Personality Disorders
Attitudinal Body-Image Assessment: Factor analysis of the body-self relations questionnaire
Journal of Personality Assessment
Binge eating, body image and depression and self-efficacy in an obese clinical population
Obesity Research
The Situational Inventory of Body-Image Dysphoria: Psychometric evidence and development of a short form
International Journal of Eating Disorders
The nature and extent of body-image disturbances in anorexia nervosa and bulimia nervosa: A meta-analysis
International Journal of Eating Disorders
The Impact of Body-Image Experiences: Development of the body image quality of life inventory
International Journal of Eating Disorders
Development of the Appearance Schemas Inventory: A new cognitive body-image assessment
Cognitive Therapy and Research
Current and vestigial effects of overweight among women: Fear of fat, attitudinal body image, and eating behaviors
Journal of Psychopathology and Behavioral Assessment
A prospective study of psychosocial aspects of gastric stapling surgery
Psychiatric Journal of the University of Ottawa
Prevalence and trends in obesity among US adults, 1999–2000
Journal of the American Medical Association
Body image in obese women before, during, and after weight loss treatment
Health Psychology
Prevalence and correlates of binge eating in a nonclinical sample of women enrolled in a weight gain prevention program
International Journal of Obesity and Related Metabolic Disorders
Psychological correlates of obesity: Moving to the next research generation
Psychological Bulletin
Social and economic consequences of overweight in adolescence in adolescence and young adulthood
New England Journal of Medicine
Cited by (185)
Efficacy and mechanisms of change in exposure-based and cognitive stand-alone body image interventions in women with overweight and obesity
2022, Behaviour Research and TherapyObesity stigma and its impact on health: A narrative review
2022, Endocrinologia, Diabetes y NutricionAssociation of body image dissatisfaction, behavioral responses for healthy eating, and cardiovascular health in African-American women with overweight or obesity: A preliminary study
2021, American Journal of Preventive Cardiology