Elsevier

Body Image

Volume 1, Issue 2, May 2004, Pages 155-167
Body Image

Body image and psychosocial differences among stable average weight, currently overweight, and formerly overweight women: the role of stigmatizing experiences

https://doi.org/10.1016/j.bodyim.2003.12.001Get rights and content

Abstract

Substantial research has compared obese and nonobese persons on body image and psychosocial adjustment. While differences in body satisfaction are often observed, the literature is less clear on other dimensions. Extant differences are typically thought to result from the social stigmatization and maltreatment experienced by obese persons, especially females. The present study of 165 women compared three cohorts who were currently overweight, never overweight, or formerly overweight. Relative to never-overweight women, currently overweight women reported more body dissatisfaction/distress, overweight preoccupation, and dysfunctional appearance investment, as well as more binge eating, lower social self-esteem, and less satisfaction with life. Consistent with the “phantom fat” phenomenon, formerly overweight women were comparable to currently overweight women but worse than never-overweight women on overweight preoccupation and dysfunctional appearance investment. Correlations confirmed that, among overweight but not formerly overweight women, more frequent stigmatizing experiences during childhood, adolescence, and adulthood were significantly associated with currently poorer body image and psychosocial functioning. Scientific and clinical implications of the findings are discussed.

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

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