© Springer International Publishing AG 2017
Sanjeev Sockalingam and Raed Hawa (eds.)Psychiatric Care in Severe Obesity10.1007/978-3-319-42536-8_88. Weight-Based Stigma and Body Image in Severe Obesity
(1)
Department of Psychology, Ryerson University, 350 Victoria St, Toronto, ON, Canada, M5B 2K3
(2)
Department of Psychiatry, University of Toronto, Toronto, ON, Canada
(3)
Centre for Mental Health, University Health Network, Toronto, ON, Canada
Case Vignettes
Ms. Smith is a 30-year-old woman referred by her primary care physician for a psychosocial assessment of body image concerns, emotional eating, and depression. She also reports currently experiencing a number of medical complications associated with obesity (current body mass index [BMI] = 40 kg/m2), including type 2 diabetes and sleep apnea. Ms. Smith describes a long-standing history of mental health issues beginning at age 7 when she first began being bullied by her peers for being overweight. She also reports being criticized by her parents as being “fat” and “lazy” throughout her childhood and adolescence. Ms. Smith states that these comments precipitated a vicious cycle of chronic dieting and emotional overeating, which has continued throughout her adult life. Ms. Smith also describes her weight as an impediment in romantic relationships, stating that former romantic partners have ended relationships with her because “they are embarrassed to have an obese girlfriend”. Similarly, she reports a recent experience of discrimination in the workplace, in which her boss threatened to fire Ms. Smith if she did not lose weight to “look better in her uniform”. When asked to describe how she currently feels about her body image and weight, Ms. Smith endorses internalizing anti-fat attitudes, stating, “I feel depressed and disgusted with myself every time I look in the mirror. I am incompetent and unlovable because I cannot seem to lose weight and keep it off”.
8.1 Introduction
In this chapter, we first review the negative effects associated with weight-based stigma and discrimination in individuals with severe obesity, challenges with the assessment of these constructs, and some promising psychosocial interventions for stigma reduction. We then provide an overview of body image in individuals with severe obesity, including body image concerns, the impact of weight loss and psychosocial interventions on body image, and issues regarding the assessment of body image in individuals with severe obesity. Finally, we return to the case example and discuss some tools that can be used to assess weight-related stigma/discrimination and body image in individuals with severe obesity .
8.2 Weight-Based Stigma in Individuals with Severe Obesity
Weight-based stigma , defined as negative attitudes towards individuals on the basis of their weight and shape, is often considered to be the last socially acceptable form of bias [1, 2]. Commonly endorsed stereotypes about individuals with obesity include beliefs that they are lazy, overemotional, sexually inexperienced, and lacking self-control [2]. These biases are pervasive, and have been reported in numerous populations, including children [3], high school teachers [4], and college students [5]. Even healthcare professionals are not immune to weight-based stigma; in fact, anti-fat biases have been endorsed by dietetics students [6], registered nurses [7], psychologists [8], primary care physicians [9], and healthcare professionals specializing in obesity [10].
Although some researchers have proposed that stigma could be harnessed as an effective strategy for targeting public health concerns such as obesity [11, 12], there is little evidence to suggest that being a target of weight-based stigma improves weight loss outcomes. Experiencing weight-based stigma instead produces a paradoxical effect [13], such that targeted individuals have been found to demonstrate poorer weight loss outcomes in a behavioural weight loss treatment program [14], as well as avoidance of exercise [15]. Experimental studies highlight the same phenomenon: exposure to weight-based stigmatizing news articles actually increases caloric consumption among women who self-identify as overweight or obese [13]. In addition to poorer weight loss outcomes, experiencing weight-based stigma is also associated with numerous adverse psychological and physical health outcomes, including increased rates of psychological distress [16], disordered eating [16], and suicide ideation [17].
8.2.1 Stigma, Perceived Discrimination, and Internalized Weight Bias
8.2.1.1 Stigma
According to sociologist Erving Goffman [18], stigma is defined as an “attribute that is deeply discrediting” for the individual (p. 3). Goffman states that there are three different types of stigma: “abominations of the body” (i.e. stigmas associated with physical disfigurement), “blemishes of individual character” (i.e. characterological stigmas such as sexual orientation or mental illness), and “tribal stigmas” (i.e. stigmas such as race that are passed on from one generation to the next; p. 4). Given that obesity is associated with physical unattractiveness [19, 20] and a host of negative personality characteristics [2], obesity can be conceptualized as both a physical and characterological stigma [21]. Additionally, unlike many other forms of stigma, individuals who are overweight or obese are typically considered to be personally responsible for their condition [22], which in turn makes them more vulnerable to the experience of discrimination [21]. These findings are consistent with attribution theory, which proposes that both stigmatized individuals and their observers undergo a process whereby they seek to determine the cause of a stigma (i.e. the reason why an individual is obese). Weiner and colleagues [22] describe that often the stigma itself (i.e. obesity) is associated with an attribution (e.g. laziness, poor self-control), which then prevents individuals from looking for other plausible causes of an individual’s condition (e.g. genetics, differences in metabolism).
Although the majority of research studies thus far have focused on individuals’ (both obese and non-obese) attitudes towards those with obesity [3–10], more recent studies have begun to focus on the experiences of individuals who are overweight or obese. With respect to stigma specifically, researchers have begun exploring individuals’ concerns over experiencing weight stigma [13, 23], suggesting that even suspecting or anticipating weight stigma may lead to deleterious outcomes [23].
8.2.1.2 Perceived Discrimination
Weight-based stigma often leads to discriminatory treatment against individuals with obesity, which can be defined as “the inappropriate and potentially unfair treatment of individuals due to group membership” ([24], p. 8). Individuals with obesity report experiencing discriminatory treatment in a number of situations, including healthcare, employment, and educational settings, as well as within interpersonal relationships [25]. Andreyeva, Puhl, and Brownell [26] measured the prevalence of perceived discrimination in the United States related to individuals’ weight or height, and found that the prevalence of perceived weight/height discrimination has increased by 66% in recent years, from 7.3% in 1996 to 12.2% in 2006. Although average BMI remained relatively stable across weight categories over the 10-year period (aside from the category of BMI ≥ 45 kg/m2), the prevalence of weight/height discrimination nevertheless increased for each BMI category for people with a BMI of 27–29 kg/m2 (overweight) and 31–40 kg/m2 (obese).
Prevalence ratings of perceived discrimination increase substantially when considering individuals who are severely obese. Puhl, Andreyeva, and Brownell [27] found that 40% of individuals with a BMI ≥ 35 kg/m2 reported experiencing either some major form of lifetime weight/height discrimination (e.g. being denied a bank loan) or daily interpersonal discrimination (e.g. being called names or insulted), with discrimination in employment-based settings occurring most frequently. When comparing the prevalence of weight/height discrimination to other types of discrimination, weight/height discrimination was the third most prevalent form of perceived discrimination for women (following gender and age) and the fourth most prevalent form of discrimination among men and women combined (following gender, age, and race) [27]. Taken together, these findings demonstrate that perceived weight discrimination is highly prevalent within society today, and is growing at a rate that exceeds the rising prevalence of obesity .
8.2.1.3 Internalized Weight Bias
In addition to examining concerns regarding weight-based stigma and perceived discrimination in individuals with obesity, researchers have also begun to assess whether they internalize negative attitudes regarding weight. Unlike other minority groups (e.g. Asians, gay/bisexual men and women), individuals who are overweight or obese do not demonstrate a favourable in-group bias [1, 28, 29], and instead actually internalize anti-fat stereotypes [1, 30, 31].
There are a number of differences between individuals with obesity and other stigmatized groups (e.g. race, sexual orientation) that may account for the lack of favourable in-group bias. First, Major, Eliezer, and Rieck [32] highlight that individuals often become obese later in life, which allows them a substantial amount of time to internalize the negative stereotypes against those with obesity prior to becoming obese and joining that group themselves. Second, individuals who are obese might perceive that they can disassociate from the stigmatized group at any time by losing weight, which may prevent them from connecting to the group and learning to dispel negative obesity stereotypes [28]. Finally, although most diets do not lead to long-term positive health or weight loss benefits [33], obesity is often perceived to be within an individual’s personal control [22]. Given that stigmas associated with greater perceived controllability have been found to engender less pity, greater levels of anger, and less willingness to assist [34], individuals who are obese must cope with this additional contributor to stigma not present in many other stigmatized groups (e.g. race, gender, age).
8.2.2 Weight-Based Stigma and Negative Outcomes
Research conducted to date demonstrates that weight stigma concerns, perceived weight-based discrimination, and weight bias internalization are each associated with a host of negative outcomes among individuals who are overweight or obese. Controlling for BMI, adverse outcomes include increased rates of depression and anxiety [35], poorer weight loss treatment outcomes in a behavioural weight loss treatment program [14], as well as greater impairment in mental and physical quality of life [36]. Accordingly, Puhl and Heuer [37] highlight that weight stigma is a serious public health concern that must be properly addressed in order to target the obesity epidemic.
Much of the research examining the relations between weight-based stigma and binge eating has focused specifically on weight bias internalization. Weight bias internalization has been associated with objective binge eating episodes in adolescents seeking bariatric surgery [38], and with increased binge eating in adult men and women with obesity [39], including those seeking weight loss treatment [40]. Similarly, Durso and Latner [30] demonstrated that weight bias internalization was associated with greater binge frequency over a 6-month period in a group of adults who were overweight or obese.
The effects of experiencing weight-based stigma and perceiving weight-based discrimination have also been examined in relation to binge eating and emotional eating. For example, in a sample of adults seeking bariatric surgery, Friedman and colleagues [35] found that the frequency of stigmatizing situations experienced within the past month predicted greater emotional eating and a current diagnosis of Binge Eating Disorder (BED) . Furthermore, increased frequency of stigmatizing situations has also been associated with higher rates of binge eating and poorer weight loss treatment outcomes in adults enrolled in a behavioural weight loss treatment programme [14]. Finally, Ashmore and colleagues [16] found that lifetime occurrence of weight stigmatization was associated with increased rates of binge eating in adults with obesity. Regarding perceived discrimination, Farrow and Tarrant [41] found that perceived weight-based discrimination among college students with varied BMIs was associated with greater emotional eating. Similarly, in a sample of adults with varied BMIs, Durso and colleagues [42] found that perceived interpersonal discrimination (e.g. everyday encounters in interpersonal settings) and institutional discrimination (e.g. perceived job loss due to one’s weight) predicted greater emotional eating and higher binge eating frequency at 3 months, with stronger relations for interpersonal discrimination.
Taken together, these findings demonstrate that there is a positive association between experiencing weight-based stigma, perceiving weight-based discrimination, and internalizing anti-fat attitudes with negative psychological outcomes across a variety of populations (e.g. adults with obesity, weight loss treatment-seeking adults, bariatric surgery-seeking adolescents ).
8.2.3 Assessment of Weight-Based Stigma and Discrimination in Individuals with Severe Obesity
There are a number of challenges that impact assessment of weight-based stigma and discrimination. First, although constructs such as weight stigma concerns, perceived discrimination, and internalized weight bias are related, these terms are often erroneously used interchangeably. For example, until the development of the Weight Bias Internalization Scale (WBIS) [30], which measures the extent to which individuals who are overweight or obese endorse negative attributions about obesity as being true for themselves specifically, measures of anti-fat attitudes were understood as representing weight bias internalization. Durso and Latner [30] posit that holding negative attributions towards individuals who are overweight or obese does not necessarily indicate that individuals hold these beliefs for themselves, necessitating the separation of holding anti-fat attitudes towards individuals who are overweight or obese, and weight bias internalization (i.e. holding these negative attributions about oneself).
Second, measures assessing weight stigma experiences (i.e. experiencing others making negative weight-related assumptions) are often confounded with perceived discrimination (i.e. the behavioural manifestation of stigma). For example, the Stigmatizing Situations Inventory (SSI; [43]) is a self-report scale that measures frequency of stigmatizing experiences. Three of the items on the scale assess the experience of having others make negative weight-related assumptions (e.g. “having people assume you have emotional problems because you are overweight”), whereas the remaining items refer to experiencing a variety of stigmatizing situations such as interpersonal interactions (e.g. “nasty comments from children”), physical barriers (e.g. “not being able to fit into seats at restaurants, theatres, and other public places”), and job discrimination (e.g. “losing a job because of your size”). Perceived discrimination is typically assessed in a similar manner, using self-report inventories that measure experiences of discrimination in employment, healthcare, and educational settings (e.g. “not given a job promotion”), as well as in interpersonal interactions (e.g. “receive poorer service than other people at restaurants or stores”) [26]. Thus, the experience of stigmatizing situations and perceived discrimination are both primarily measuring perceptions of interpersonal and institutional discrimination, suggesting that the experience of weight-based stigma (as it is currently measured) and perceived discrimination may in fact represent the same phenomenon.
Third, constructs including weight stigma concerns, perceived discrimination, and internalized weight bias are not typically assessed simultaneously within one research study, which hinders the interpretation of findings within and across research studies. For example, in a sample of women who were overweight or obese, Pearl, Puhl, and Dovidio [44] found that weight bias internalization was negatively correlated with motivation to exercise and self-efficacy to engage in exercise, whereas weight stigma experiences were positively correlated with current exercise frequency. These findings suggest that varied weight stigma constructs may be associated with differential health-related outcomes.
Finally, a major limitation with the current assessment of weight-based stigma and discrimination is the lack of widely used measures with good psychometric properties. Researchers often develop their own individual measures to assess the desired constructs within their studies, which further hinders cross-study comparisons .
8.2.4 Treatment of Internalized Weight-Based Stigma
Studies evaluating the effectiveness of weight-based stigma reduction interventions have been described as the most needed studies to advance society’s understanding of weight-based stigma [25]. To date, only one study has examined the impact of a therapeutic intervention on internalized stigma and perceived discrimination reduction in individuals with obesity. Lillis and colleagues [45] found that a 6-hour mindfulness and acceptance-based workshop that focused on teaching participants to mindfully accept (rather than avoid) their stigmatizing experiences was effective in improving obesity-related stigma and psychological distress 3 months following the workshop in treatment-seeking adults with obesity. These preliminary results suggest that acceptance and mindfulness-based therapeutic interventions may help to reduce internalized stigma and perceived discrimination in individuals with severe obesity. Furthermore, interventions that incorporate compassion-focused techniques, psychoeducation, and cognitive restructuring have all demonstrated promising results in other stigmatized populations (e.g. HIV-positive gay and bisexual men; individuals with mental illness; [46, 47]), and could potentially be modified for individuals with severe obesity .
8.3 Body Image in Individuals with Severe Obesity
Body image refers to an individual’s beliefs, perceptions, cognitions, emotions, and behaviours pertaining to his/her physical appearance [48, 49]. The factors contributing to body image are complex and multidimensional [50]. Historical influences on body image include factors such as cultural socialization, interpersonal experiences, physical characteristics and changes, and personality factors [50]. Cultural socialization includes messages that are disseminated regarding the cultural ideal of attractiveness—for example, thinness is valued whereas obesity is stigmatized; therefore, people are expected to engage in body modification through diet, exercise, and medical procedures to achieve the societal expectation. Interpersonal experiences contributing to body image include weight-based teasing, rejection, or criticism by family, peers, and others, as well as weight-based discrimination. The extent of discrepancy that exists between a person’s actual physical characteristics and the cultural ideal impacts not only how the person is evaluated and treated by others, but also how the person evaluates him- or herself. In addition, the evaluation depends on changes in physical characteristics, such as whether a person has recently been gaining or losing weight [51]. Moreover, those with predisposing personality characteristics, such as low self-esteem and perfectionism, are at heightened risk of developing negative body image. These historical influences are not mutually exclusive, but rather, interact in complex ways to influence body image. Moreover, the historical influences are helpful in understanding the ways in which weight-based stigma and discrimination contribute to body image.
8.3.1 Body Image Concerns in Individuals with Obesity
There is a strong link between obesity and poor body image [51]; however, substantial heterogeneity exists among individuals with obesity. Some of the factors that have been shown to increase the risk of body image concerns include female gender, presence of binge eating disorder, current weight gain trajectory, and the subjective experience of weight cycling (more so than objective weight fluctuations) [51].
Much of the research examining body image in individuals with obesity has focused on women, likely because they are over-represented among treatment-seeking samples. However, studies including both men and women suggest that body image concerns are greater among women [51]. The majority of women with obesity report negative body image concerning their weight, and approximately half identify their abdomen and waist region as the greatest area of concern [52]. Although body image concerns are prevalent among women in the community, the concerns reported by women with obesity exceed those reported by non-obese women [51–53]. For example, women seeking weight loss surgery report less appearance satisfaction, greater body image dysphoria, and greater impairment in body image quality of life relative to normative samples [54].
8.3.2 The Impact of Negative Body Image
Individuals with obesity do not necessarily have higher rates of psychological distress than non-obese individuals; however, negative body image has been proposed as a potential mediator of the relationship between obesity and psychological distress [55]. That is, individuals with obesity and poor body image will be at increased risk of psychological symptoms relative to those without significant body image concerns. Body image has indeed been shown to partially mediate the relationship between obesity and psychological symptoms (depression and low self-esteem) in treatment-seeking men and women [35].
It is a dangerous misconception that the psychological distress associated with weight-based stigma and discrimination should motivate individuals with obesity to lose weight. Some psychological distress is likely required for most people (including healthy weight individuals) to persist in making all types of behavioural changes. However, high levels of distress (e.g. negative body image, depression, low self-esteem) can be very counterproductive to weight loss efforts because it can cause people to feel self-conscious while engaging in physical activity and doubt their likelihood of successful weight loss through diet and exercise, which in turn makes it difficult to persist with healthy behavioural changes [51, 53]. In fact, body dissatisfaction and psychological distress can actually be a trigger for eating and weight-related problems [56].
8.3.3 The Impact of Weight Loss on Body Image
The desire to improve appearance and body image is often reported as being among the most important motives for weight loss [57]. A recent systematic review and meta-analysis reported that body image improves in individuals with obesity enrolled in weight loss programmes [58]. A recent study found that women with severe obesity participating in a 6-month behavioural intervention focused on nutrition and physical activity improved their weight, and that weight loss was a mediator of improved body satisfaction [59]. Importantly, improvements in body image are typically observed with modest weight loss, and prior to achieving a healthy weight. For example, significant improvements in body image have been reported in individuals who lose 5–10 % of their body weight through a behavioural weight loss program; however, improvements in body image observed during weight loss treatment begin to deteriorate if weight regain occurs [60]. Even for previously overweight individuals who are able to maintain a healthy weight, their body image typically remains lower relative to individuals who have never been overweight. This phenomenon of residual body image concerns following weight loss has been termed “phantom fat” [61].
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