International Journal of Obesity (1999) 23, 221±230
ß 1999 Stockton Press All rights reserved 0307±0565/99 $12.00
http://www.stockton-press.co.uk/ijo
Obesity stigmatization and coping: Relation to
mental health symptoms, body image, and selfesteem
A Myers and JC Rosen
Department of Psychology, University of Vermont, Burlington, VT, USA
OBJECTIVE: To create inventories of stigmatizing situations faced by obese people and ways of coping with
stigmatization, and to examine how stigma and coping are related to psychological distress in an obese patient
population.
DESIGN: Study 1: Items were generated by asking obese people to list stigmatizing situations they had encountered
and their ways of coping. Study 2: Obese patients were surveyed about the frequency with which they encountered
each form of stigmatization and employed each form of coping. Cross-sectional data on current psychological
adjustment were obtained.
SUBJECTS: Study 1: 63 obese patients (body mass index, BMI > 40 kg=m2); 38 obese non-patients, seven professionals who work with obese patients and 32 obese female authors from the print media. Study 2: 112 gastric bypass
patients (BMI 33.9 ± 80.9 kg=m2) and 34 less obese patients (BMI 27.1 ± 57.2 kg=m2).
MEASUREMENT: Study 1: Collection of stigmatizing situations and coping responses. Study 2: Frequency of
stigmatizing experiences and coping responses, psychological symptoms, body image, and self esteem measures.
RESULTS: Study 1 resulted in two objective questionnaires, consisting of 50 situations and 99 responses. Study 2
found that stigmatization is a common experience, and that obese subjects frequently engage in some effort to cope
with stigma. More frequent exposure to stigmatization was associated with greater psychological distress, more
attempts to cope, and more severe obesity. Certain coping strategies are associated with greater distress.
Keywords: obesity stigma; coping; gastric bypass
Introduction
Individuals who share the stigma of obesity quickly
®nd that stigmatization affects nearly every aspect of
their lives. Obese people report job discrimination,
social exclusion, exploitation by the diet and ®tness
industry, denial of health bene®ts, trouble ®nding
clothing, mistreatment by doctors, and public
ridicule.1 ± 3 Additionally, obese people are less
likely to be admitted to college4 or to have their
education funded.5 Obese people are more likely to
be of lower socioeconomic status6 and to decrease in
socioeconomic status over time.7
Unlike racial prejudice, society freely expresses
prejudicial attitudes towards obese people, justifying
these attitudes on the grounds that weight is controllable.5 Thus, obese people may be more likely than
other minority groups to encounter overt hostility and
discrimination. Negative stereotypes of obese people
include the views that they are ugly, morally and
emotionally impaired, asexual, discontented, weakwilled and unlikable.5 Ironically, obese people are
just as likely as non-obese people to hold these
prejudiced attitudes.5
Correspondence: James Rosen, Department of Psychology,
University of Vermont, Burlington, VT 0545, USA
Received 22 July 1997; revised 3 April 1998; accepted 24 July
1998
Some recent studies have attempted to quantify
different types of stigmatizing experiences faced by
obese people. For example, a survey of 445 members
of the National Association to Advance Fat Acceptance (NAAFA) found that 98% reported verbal
harassment, criticism, or teasing from family and
friends.3 On the job, 75% reported criticism or teasing
in general, and 50% reported criticism or teasing from
supervisors. Of this sample, 33% reported being called
negative names by health professionals, and about half
felt that they had not been hired for a job due to size
discrimination.
In a study of 492 readers of Weight Watchers
magazine, Rothblum8 found that 40% reported receiving nasty comments from co-workers about their
weight, 29% reported being made less visible to
clients while at work, 27% of female respondents
reported being ®red or denied choice assignments
because of their weight, 22% reported having their
work denigrated because of their weight, and 25%
said that they were self-employed or wanted to be
self-employed in order to avoid these situations.8
Reports of negative weight-related incidents increased
as respondents' degree of overweight increased.
In a study of 57 consecutive gastric bypass surgery
patients, Rand and MacGregor2 also found that their
severely obese patients reported several types of
stigmatizing encounters. For example, 91% said that
people at work had a negative attitude about them
Obesity stigmatization
A Myers and JC Rosen
222
because of their weight, while 87% felt that their
weight had affected potential employers' decision to
hire them. Additionally, 84% said they did not like to
be seen in public, and 81% said that they avoided fast
food restaurants in order to avoid stigma. The authors
demonstrated dramatic decreases in the number of
stigmatizing situations reported by these patients after
they lost weight as the result of gastric bypass surgery.
A limitation of these studies is that in all of them,
stigmatizing situations were de®ned by the researchers rather than by obese persons themselves. Although
discrimination in the workplace appears to be a major
problem, there may be many other experiences of
stigmatization that affect the well-being of obese
persons. To date, no study has identi®ed a comprehensive list of common stigmatizing experiences
faced by obese persons. Creating such a list was one
objective of the present study. Basic information
about the type and frequency of stigmatization is
important for understanding and modifying the psychosocial problems faced by obese people.
Although the prevalence of psychopathology is no
greater in obese than non-obese samples,9 obesity
stigmatization is a challenging experience that spoils
quality of life, triggers psychological distress, and
requires substantial coping efforts. To date, however,
no study has empirically demonstrated a relation
between stigmatizing experiences and mental health
symptoms. Exploring this relation was a second
objective of this study.
A third objective of this study was to identify the
common strategies that obese persons use to cope with
stigma and to evaluate the relation between their
coping strategies and mental health adjustment. Generally, people believe that the best way to eliminate
unwanted experiences of stigmatization is to lose
weight. However, because weight reduction is not a
permanent, effective solution for most obese persons,10 they must rely on psychosocial strategies to
cope with stigmatization.
Little research has been done on psychosocial strategies for combating stigmatization. Several educational
and psychotherapeutic approaches have been described
for obese patients with negative self-esteem or anger in
connection with stigmatization and body weight dissatisfaction.11 ± 15 More positive body image, more positive self-esteem, and less negative attitudes toward their
own obesity are among the results in people who
undergo some of these programs.13,14 It is unknown,
however, if patients are better able to cope with stigmatization encounters after such counseling. Moreover, the
recommendations given for coping with stigmatization
in these programs are not derived from any empirical
study of coping among obese persons. Some recommendations are simply extrapolations from the literature
on how people cope with other forms of stigma (for
example, physical disability).
In the popular literature as well, there is a dearth of
information available about how obese people can
combat their stigmatization. In preparation for this
study, the authors examined current self-help books
(written by health professionals about weight loss,
eating disorders, or body image and available at a
national book retailer) for advice on coping with obesity
stigmatization. Only four of the 32 books included
strategies for combating stigmatization.16 ± 19 The
authors recommended being assertive with critics, joining size-acceptance organizations such as NAAFA,
surrounding oneself with positive images of fat
people, practicing self-acceptance, and doing cognitive
restructuring. Another source of advice about coping
with obesity stigmatization is `size positive' consumer
magazines, such as Radiance and Dimensions.
How frequent and how representative the coping
techniques recommended by such authors are, among
obese persons, is unknown. Moreover, other than
testimonials, there is no information about the effectiveness of different coping techniques on psychosocial functioning. In summary, there appears to be no
systematic study of the strategies used by obese
persons to cope with stigmatization. More basic
information about this topic could be useful in psychosocial interventions for obesity, and exploring this
area was thus the third objective of this research.
A fourth, and ®nal, purpose of this research was to
explore the relation between forms for coping with
obesity stigmatization and psychological adjustment.
Psychological research on coping ®nds that coping
strategies differ according to whether a person
attempts to engage or disengage from a problem,
with engaged coping strategies generally being related
to better psychological outcomes.20 Tobin et al20 have
identi®ed either primary dimensions of coping,
including four `engaged' coping strategies (problemsolving, cognitive restructuring, emotional expression,
and social support) and four `disengaged' coping
strategies (problem avoidance, wishful thinking, selfcriticism, and social withdrawal). While no attempt
has been made to apply these dimensions of coping to
the problem of obesity stigma, we hoped to examine
the relation between coping attempts reported by our
respondents and their psychological adjustment, in
order to see if particular forms of coping appeared
relatively more adaptive or maladaptive and to see
whether our ®ndings were consistent with previous
research.
Study 1: Development of obesity
stigmatization and coping
inventories
Method and results
The purpose of this study was to generate two inventories, one of stigmatizing encounters experienced by
obese people and the second of their ways of coping.
Obesity stigmatization
A Myers and JC Rosen
We performed content analyses on a large set of these
experiences in order to develop a more concise,
representative and reliable set of items for closeended stigmatization and coping questionnaires.
Subjects
Subjects included clinical and non-clinical samples of
obese persons, a small sample of professionals who
work with obese persons, and obese authors from the
print media.
Clinical subjects. There were 63 consecutive
severely obese patients (42 female, 21 male) in a
gastric bypass surgery program. Some subjects had
already undergone gastric bypass surgery and lost
weight, while others were pre-operative candidates.
All subjects were, or had been pre-operatively, at a
body mass index (BMI) 40 kg=m2.
Non-clinical subjects. These included 38 members
(32 female, 6 male) of an electronic mail list service
known as `[email protected].' The `welcome' message for new subscribers to this e-mail list
describes it as `a list for fat people, their allies, and
friends. It provides a supportive space to talk about
issues affecting fat people. It is explicitly in favor of
size acceptance and living well as a fat person.' The
38 respondents consisted of subscribers who
responded to a request for people's experiences of
stigmatization and discrimination. All respondents
were informed that their responses would be used
for research, and the researcher requested that respondents be fat themselves, rather than `allies and friends'
of fat people.
These two samples of obese persons were asked to
complete an open-ended questionnaire on stigmatizing situations and coping responses:
Being overweight can cause problems for people, not
only medically, but in social situations as well.
1) Please describe a negative experience related to
your weight that has occurred with another person
within the last four weeks.
2) Please describe in detail how you coped with the
situation.
3) What do you think is the best way to cope with
other people's negative reactions to your weight?
4) What coping strategies or supports would you
recommend to another overweight person facing
the same situation you described in 1 above?
By asking for experiences within the past month, we
hoped to identify common experiences in addition to
more dramatic events, as well as to facilitate participants' recall of these events.
Professional respondents. These were seven out of
69 members of the Association for the Advancement
of Behavior Therapy special interest group on eating
disorders and obesity, who responded to an openended questionnaire. These doctoral psychologists
with experience helping obese patients were asked
to describe how they assisted or recommended that
their clients cope with stigmatizing situations.
Print media. These data were obtained from 32
female authors of articles or vignettes in Journeys to
Self-Acceptance: Fat Women Speak Out,21 and Radiance: A Magazine for Large Women (v. 8±12, 1991±
1995), two sources that provide ®rsthand accounts of
obese persons' stigmatizing experiences and
responses.
Responses from the questionnaires sent to professionals and relevant passages from the 32 vignettes=articles were compiled verbatim into sentences
and phrases that described distinct stigmatizing and
coping experiences.
Content analysis and derivation of items
A total of 185 stigmatizing experiences and 382
coping responses were reported. Six raters, including
one psychologist and ®ve psychology graduate students with clinical or research experience in body
image and obesity, read the lists of stigmatizing and
coping experiences and independently de®ned themes.
Themes that were identi®ed by at least four out of six
raters were retained for the next step. Eleven stigma
and 21 coping categories were reliably identi®ed (see
Table 1 and Table 2). All stigmatizing situations and
coping responses were then sorted into these categories by three graduate student raters. Items that
were reliably sorted by at least two of the three
raters were retained.
Two raters, a doctoral psychologist and a graduate
student in clinical psychology, eliminated redundant
responses and combined speci®c instances of the same
event into more general terms. Responses were reworded concisely and in a consistent format that
would be appropriate for a close-ended questionnaire.
The ®nal questionnaires, named `Stigmatizing
Situations' and `Coping Responses,' consisted of 50
and 99 items, respectively, with each category being
represented by 1±11 items. For Stigmatizing Situations, the instructions to the respondent read: `Below
is a list of situations that some people encounter
because of their weight. Indicate whether, and how
often, each of these situations happens to you.' For
Coping Responses, the instructions read: `The following are some strategies people use in order to deal
with negative situations related to their weight. For
example, someone who hears an insult about her
appearance may make herself feel better by insulting
the person back. Using the scale below, please indicate whether, and how often, you have used each of
the following strategies to cope with the sorts of
situations listed [in the previous inventory].' A tenpoint ordinal scale with descriptive anchor points was
223
Obesity stigmatization
A Myers and JC Rosen
224
Table 1
Stigmatizing situations in descending order of frequency
Category and sample items
Item mean (s.d.)
Alpha
1. Comments from children (four items)
``As an adult, having a child make fun of you.''
``A child coming up to you and saying something like, `You're fat!' ''
2.88 (2.0)
0.81
2. Others making negative assumptions about you. . . (three items)
``Other people having low expectations of you because of your weight.''
``Having people assume you have emotional problems because you are overweight.''
2.49 (1.8)
0.60
3. Physical barriers (seven items)
``Not being able to ®t into seats at restaurants, theaters, and other public places.''
``Not being able to ®nd clothes that ®t.''
2.14 (1.7)
0.83
4. Being stared at (®ve items)
``Being stared at in public.''
``Groups of people pointing and laughing at you in public.''
1.90 (1.2)
0.71
5. Inappropriate comments from doctors (four items)
``Having a doctor make cruel remarks, ridicule you, or call you names.''
``A doctor blaming unrelated physical problems on your weight.''
1.88 (1.4)
0.86
6. Nasty comments from family (seven items)
``A spouse/partner calling you names because of your weight.''
``A parent or other relative nagging you to lose weight.''
1.88 (2.2)
0.77
7. Nasty comments from others (11 items)
``Having strangers suggest diets to you.''
``Being offered fashion advice from strangers.''
1.83 (1.3)
0.87
8. Being avoided, excluded, ignored (two items)
``Being unable to get a date because of your size.''
``Being singled out as a child by a teacher, school nurse, etc. because of your size.''
1.78 (1.4)
0.58
9. Loved ones embarrassed by your size (three items)
``Having a spouse or partner be ashamed to admit being with you.''
``Having family members feel embarrassed by you or ashamed of you.''
1.53 (1.4)
0.48
10. Job discrimination (three items)
``Losing a job because of your size.''
``Not being hired because of your weight, shape, or size.''
11. Being physically attacked (one item)
``Being hit, beaten up, or physically attacked because of your weight.''
0.88 (1.3)
0.63
0.47 (1.5)
±
TOTAL
1.90 (2.0)
0.95
used (0 ˆ `never', 1 ˆ `once in your life', 2 ˆ `several
times in your life', 3 ˆ `about once=year', 4 ˆ `several
times=year', 5 ˆ `about once a month', 6 ˆ `several
times=month', 7 ˆ `about once=week', 8 ˆ `several
times=week', 9 ˆ `daily'). Sample items are listed
with the categories in Table 1 and Table 2. The
questionnaires are available from the authors.
Study 2: Descriptive and validity
study of obesity stigmatization and
coping
Method
The purpose of this study was to examine the frequency of different types of stigmatizing situations
faced by obese people, their ways of coping, and the
relation of these variables to psychological adjustment. In addition, the validity of the stigma questionnaires was tested by comparing groups of subjects
with different levels of obesity.
Subjects
A total of 394 people were invited to participate. Of
these, 277 were severely obese patients at two gastric
bypass surgery clinics in Vermont and Florida, USA.
Additionally, 117 were mild to moderately obese
patients who had participated in weight loss studies
involving drug treatment and nutritional counseling.
Therefore, both were clinical samples of people seeking
treatment for obesity. Of the surveys distributed, 112
were returned by gastric bypass patients and 34 by
weight-loss study patients, for a total response rate of
37%. The full sample included 112 women and 34 men
(age: mean ˆ 42.13 y, s.d. ˆ 9.8, range ˆ 16±70 y; race:
91.1% Caucasian, 3.4% African-American, 2.1%
Native American, 3.4% Other; pre-treatment weight
(lbs): mean ˆ 307.8, s.d. ˆ 92.3, range ˆ 153±630;
pre-treatment BMI: mean ˆ 49.55 kg=m2, s.d. ˆ 12.8,
range ˆ 27.1±80.9 kg=m2).
Measures
Participants completed questionnaires individually
and returned them in postage-paid envelopes. All
were invited to include their names and addresses,
which were then entered into a lottery for two $50
Obesity stigmatization
A Myers and JC Rosen
225
Table 2
Coping responses in descending order of frequency
Category and sample items
Item mean (s.d.)
Alpha
1. Positive self-talk (10 items)
``I think, `It's who I am on the inside that matters.' ''
``I think that no one has the right to judge me.''
4.52 (2.2)
0.86
2. ``Heading off'' negative remarks (three items)
``I make eye contact and say `hi' to people who might be staring.''
``I act happy, sociable, and self-con®dent so that no one thinks to bother me.''
4.49 (2.4)
0.51
3. Using faith, religion, prayer (three items)
``I think to myself, `God is on my side.' ''
``I think to myself, `I am simply not meant to be thin.' ''
4. Self-love, self-acceptance (three items)
``I do something nice for myself to make me feel better.''
``I put myself and my needs before other people's.''
4.25 (2.7)
0.66
3.71 (2.2)
0.59
5. Negative self-talk (four items)
``I think that no one will ever love me because of my weight.''
``I feel really bad about myself.''
3.71 (2.6)
0.79
6. Eating (one item)
``If people make me feel badly about my weight, I just eat more.''
3.65 (3.1)
±
7. Social support from not-fat people (®ve items)
``I get support from my spouse/partner.''
``I talk to supportive, understanding friends.''
3.52 (2.0)
0.63
8. Refuse to diet (four items)
``I think to myself that I will not diet in order to please other people.''
``I think to myself, `I can't lose weight, and so I will not try.' ''
3.47 (1.8)
0.36
9. See the situation as the other person's problem (four items)
``If people do not like me because of my size, I see it as their loss.''
``I regard people who have problems with overweight as small-minded and childish.''
10. Humor, witty comebacks or joking (three items)
``I laugh it off or joke about it.''
``I try to think of a witty comeback.''
3.46 (2.5)
0.71
3.42 (2.6)
0.75
11. Refuse to hide, be visible (six items)
``I make a point of not hiding my body.''
``I shock people by doing things `fat people shouldn't do.' ''
3.22 (1.7)
0.61
12. Ignoring situation, making no response (six items)
``I ignore them and try not to let them get to me.''
``I pretend I did not hear the remark and walk away.''
3.05 (2.0)
0.78
13. Cry, isolate myself (two items)
``I cry about it, then get over it.''
``I get depressed and isolate myself.''
3.03 (2.6)
0.67
14. Responding positively, being `nice' (eight items)
``I just say hello and am friendly.''
``I remind these people that I am a human being.''
2.72 (1.7)
0.76
15. Social support from other fat people (seven items)
``I attend a size-acceptance support group.''
``I talk to other overweight people.''
2.00 (1.3)
0.65
16. Avoid or leave situation (eight items)
``I quit jobs where I encounter stigma or discrimination.''
``I avoid looking in the mirror so that I don't have to think about my weight.''
1.77 (1.4)
0.70
17. Diet (three items)
``I go on a diet to reduce or avoid discrimination/stigma based on weight.''
``I receive weight-loss surgery (for example, gastric bypass, liposuction, etc.).''
1.72 (1.7)
0.56
18. Educate self or others about fat stigma (eight items)
``I wear buttons, T-shirts, etc. with size-positive messages.''
``I educate other people about fat acceptance and weight control.''
1.43 (1.2)
0.68
19. Responding negatively, insulting back (seven items)
``I tell the other person off.''
``If someone is staring at me, I stare back.''
1.35 (1.4)
0.77
20. Seeking therapy (two items)
``I talk to a counselor or social worker.''
``I go to therapy to get help dealing with these situations.''
21. Physical violence (two items)
``I ®ght back physically.''
``I use my size to intimidate people.''
1.22 (2.0)
0.87
0.98 (1.7)
0.33
2.83 (1.2)
0.95
TOTAL
Obesity stigmatization
A Myers and JC Rosen
226
cash prizes. Names and addresses of respondents were
separated from survey data, so that all responses
remained con®dential.
The measures included the 50-item Stigmatizing
Situations inventory and 99-item Coping Responses
inventory described above. In addition, respondents
were asked to complete measures of mental health
symptoms, body-image, and self-esteem. The Brief
Symptom Inventory (BSI)22 is a self-report measure of
mental health symptoms. We used the Global Severity
Index, which is the average severity of 53 symptoms
experienced over the past week.22 The Body Shape
Questionnaire (BSQ)23 is a 34-item scale which
measures desire to lose weight, body dissatisfaction,
feelings of low self-worth in connection to weight and
shape, and self-consciousness about weight and shape.
We used the total score on this measure as an index of
overall body image distress.23 The Rosenberg SelfEsteem (RSE) Scale24 is a 10-item questionnaire
measuring attitudes of general self-worth and global
self-esteem. The RSE has been demonstrated to have
acceptable reliability and validity.25
Results
Frequency of stigmatizing situations and coping
responses
The overall mean score for each of the ®fty stigmatizing situation items was 1.90 (s.d. ˆ 2.0). This score
corresponds to a reported frequency of `several times
in my life.' The overall mean score for each of the 99
coping responses items was 2.83 (s.d. ˆ 1.2), which
corresponds to a reported frequency of `about once a
year.'
In Table 1 and Table 2, the mean score for each
category of stigmatization and coping are presented in
descending order for the full sample of 146 respondents. In order to account for the unequal number of
items per category, we calculated these scores as the
mean of the category items.
The most frequent stigmatizing situations faced
were hurtful comments from children, other people
making un¯attering assumptions about the obese
person, and encountering physical barriers (such as
chairs that are too small). Respondents reported facing
these situations between `once a year' and `several
times in my life.' Being stared at and being subjected
to unsolicited negative comments were also frequent.
Infrequent experiences were job discrimination and
physical assault, which occurred on average less than
`once in my life.'
The most frequent coping responses employed by
obese persons were the use of positive self-statements,
attempts to `head off' negative remarks by socially
disarming people who might otherwise be critical, and
using faith, religion and prayer for self-consolation.
Respondents reported that they used these strategies
from `once a month' to `several times a year.' Infrequently used coping strategies included educating
oneself and others about obesity and obesity stigmatization, being insulting and rude to the stigmatizer,
seeking therapy because of stigma, and resorting to
physical violence. These strategies were reportedly
used an average of `once in my life.'
Results were analyzed separately by gender, including data from 34 men and 112 women, in order to
examine whether stigma is experienced more frequently by one gender or the other. The resulting
means for Stigmatizing Situations were 2.05
(s.d. ˆ 1.1) for men and 1.86 (s.d. ˆ 1.1) for women
and were not signi®cantly different. Likewise, number
of coping attempts made by men (mean ˆ 2.64,
s.d. ˆ 1.1) and women (mean ˆ 2.89, s.d. ˆ 1.2) were
not signi®cantly different.
Internal consistency
In order to assess internal consistency of the stigma
and coping inventories, Chronbach's alphas were
calculated for each measure and for each category.
For Stigmatizing Situations, the overall alpha was
0.95, and for Coping Responses it was also 0.95,
indicating that the content within each inventory is
reliably consistent. The alpha coef®cients by category
(see Table 1 and Table 2) varied greatly. Although
most were in the acceptable range, some categories
showed low consistency of content. Therefore,
although the categorization of items by our expert
raters was reliable, the content of some categories was
not very homogenous. A small number of items in
some categories also accounted for some of the low
alphas.
Validity
In order to test the validity of these inventories, we
hypothesized that the stigma and coping inventories
would discriminate between severely obese subjects
with a BMI 40 kg=m2 from subjects with a
BMI < 40 kg=m2, since we expect that persons who
are more obviously obese are subjected to more
stigmatizing situations and are forced to engage in
more coping efforts than persons who are only mild to
moderately obese.
Dividing the sample in this way resulted in 110
severely obese subjects (BMI 40) and 36 mild to
moderately obese subjects (BMI < 40). The mean of
their pre-treatment BMIs were signi®cantly different:
54.5 (s.d. ˆ 10.6; range 40.4±80.9) vs 34.2 (s.d. ˆ 3.7,
range 27.1±39.3): t ˆ 16.97 (df ˆ 141), P < 0.0001.
This division of subjects corresponded closely to the
two clinical samples. Only nine bariatric surgery
candidates had a BMI < 40 kg=m2, and seven dieting
subjects were above that level. The groups did not
Obesity stigmatization
A Myers and JC Rosen
differ on gender, race, or marital status, but did differ
in age and socioeconomic status, with the severely
obese being younger and lower in socioeconomic
status.
According to univariate analyses of covariance
controlling for age and socioeconomic status, severely
obese subjects reported signi®cantly more stigmatizing situations (F(1,135) ˆ 20.47, P < 0.0001) and
coping responses (F(1,135) ˆ 10.48, P < 0.005). Item
means for Stigmatizing Situations were 1.05
(s.d. ˆ 0.83) for less obese patients and 2.16
(s.d. ˆ 1.08) for more obese patients. On Coping
Responses, the item mean was 2.24 (s.d. ˆ 0.91) for
less obese patients, as opposed to 2.99 (s.d. ˆ 1.10) for
more obese patients.
For another test of validity and of the relation
between weight and stigmatization, we computed the
correlation (r) between Stigmatizing Situations and
pre-treatment BMI, which was 0.40 (P < 0.001) for all
subjects, 0.44 (P < 0.001) in the mild to moderately
obese group, and 0.14 (not statistically signi®cant), in
the severely obese group. Thus, beyond a cut-off of
BMI ˆ 40 kg=m2, stigmatizing situations no longer
increased in direct proportion to body mass.
There was also a signi®cant correlation between
Coping Responses and pre-treatment BMI (r ˆ 0.22,
P < 0.01), indicating that more obese subjects
reported more coping efforts. However, once we
controlled for the number of stigmatizing situations
respondents' reported, the resulting partial correlation
between Coping Responses and pre-treatment BMI
was not signi®cant (r ˆ 70.02), indicating that more
coping effort in the severely obese is merely a function of being exposed to more stigmatizing experiences. In fact, the correlation (r ˆ 0.61, P < 0.001)
between Stigmatizing Situations and Coping
Responses also indicates that coping responses
increase in direct proportion to stigmatizing experiences.
Relation of stigma, coping, and psychological distress
Stigmatizing Situations was signi®cantly correlated
with each measure of psychological adjustment (see
Table 3). A greater number of stigmatizing situations
Table 3
was associated with more mental health symptoms,
more negative body image, and more negative selfesteem.
Even after accounting for the correlation of weight
and number of stigmatizing situations encountered,
the resulting partial correlations between Stigmatizing
Situations and psychological distress measures were
statistically signi®cant, indicating that worse adjustment is not merely a function of weight, but is related
directly to stigmatization.
Coping Responses was also signi®cantly correlated
with scores on the Brief Symptom Inventory and
Body Shape Questionnaire, indicating that more
coping attempts were associated with more symptoms
and more negative body image (see Table 3). However, after controlling for both weight and the frequency of stigmatizing situations, the resulting partial
correlation of Coping Responses with psychological
adjustment measures were not signi®cant. Thus, the
apparent relation of coping and psychological distress
is more a function of exposure to stigma than of the
type or amount of coping used.
We wanted to identify some coping responses that
appeared maladaptive or adaptive in relation to psychological adjustment. Using partial correlations that
controlled for the frequency of stigmatization experiences and weight, three categories of `maladaptive'
coping were associated with more mental health
symptoms, negative body image, and negative selfesteem. These were: `Negative self-talk,' and `Cry,
isolate myself' and `Avoid or leave situation' (see
Table 4). Due to the high number of correlations
performed, we used a Bonferroni correction to control
for correlations signi®cant due to chance. After applying this correction, `Avoid or leave situation' was
signi®cantly related with negative body image and
negative self-esteem, but the relation with mental
health symptoms was only marginally signi®cant.
Initially, we also expected to ®nd some types of
`adaptive coping' which would be associated with
lower scores on the BSI (mental health symptoms),
lower scores on the BSQ (body image), and higher
scores on the RSE (self-esteem). No coping categories
met this description. However, four coping categories
had signi®cant partial correlations with the RSE, as
well as correlations with the BSI and BSQ that, while
Correlations of stigmatizing situations and coping with psychological distress
Stigmatizing situations
Scale
Brief symptom inventory
Body shape questionnaire
Rosenberg self-esteem
Coping responses
Correlation (r)
Partial Correlationa
Correlation (r)
Partial Correlation b
0.33***
0.29***
70.24**
0.31***
0.30***
70.21**
0.32***
0.29***
70.14
0.12
0.13
70.01
** P < 0.01
*** P < 0.001
a
Controls for effects of pre-treatment body mass index (BMI)
b
Controls for effects of pre-treatment BMI and number of stigmatizing situations
227
Obesity stigmatization
A Myers and JC Rosen
228
Table 4
Relation between form of coping and psychological distress
Partial Correlationa (r) with:
Category
Negative self-talk
Cry, isolate myself
Avoid or leave situation
Eat
Fight back physically
Seek therapy
Respond negatively
Seek support of fat people
Diet
Educate others/self
Use faith, religion, prayer
Respond positively
Seek social support
Ignore situation
Head off negative remarks
Use humor
Refuse to diet
Positive self-talk
See situation as others' problem
Refuse to hide body, be visible
Self-love, self acceptance
BSI
BSQ
RSE
0.41***
0.38***
0.22*
0.06
0.33***
0.21
0.21
0.17
70.03
0.19
0.11
0.02
0.10
70.01
70.12
70.01
70.10
70.06
70.01
70.04
70.12
0.49***
0.43***
0.33***
0.32***
0.13
0.11
0.01
0.05
0.18
70.02
0.11
0.01
0.08
0.08
0.01
70.01
70.13
70.01
70.03
70.05
70.14
70.61***
70.57***
70.37***
70.29***
70.09
70.22*
70.05
70.19
70.10
0.10
70.10
0.02
0.00
0.04
0.13
0.07
0.10
0.17
0.24**
0.28***
0.37***
* P < 0.01 (not signi®cant after Bonferroni correction)
** P < 0.005
*** P < 0.001
a
Controls for effects of pre-treatment BMI and number of stigmatizing situations
BSI ˆ brief
symptom
inventory;
BSQ ˆ body
shape
questionnaire;
RSE ˆ Rosenberg self esteem scale
not statistically signi®cant, were in the predicted
direction. These categories, shown in Table 4,
included `Positive self-talk,' `See situation as the
other person's problem,' `Refuse to hide body, be
visible' and `Self-love, self-acceptance.'
Discussion
The main purpose of this project was to generate a set
of stigmatization experiences and coping responses
that occur with some frequency among obese persons.
Other studies of obesity stigmatization have relied on
experiences that were predetermined by the investigators. In this study, however, respondents reported
their own experiences with stigmatization in an openended format, resulting in what we believe is a more
representative set of stigmatization and coping experiences. A total of 50 stigmatization experiences and 99
coping responses were identi®ed, including experiences reported previously as well as others that have
not received much attention.
According to the mean ratings found in Study 2, we
conclude that stigmatization is a common experience
for obese people, because on average each experience
occurred `several times' in respondents' lives.
Furthermore, respondents reported that they used
each of the coping responses an average of `once a
year,' which leads to the conclusion that they were
making some attempt to cope with obesity stigma
every few days.
Not surprisingly, frequency of stigmatization
experiences varies with weight. Obesity is a visible
stigma, and the more deviant the body size, the more
stigmatization experiences the individual would be
expected to suffer. Nonetheless, beyond a cutoff
weight indicative of severe obesity, weight and stigmatization were not strongly related. Therefore, for
example, an extra 50 kg in persons weighing 130 kg or
more appears to have little additional effect on their
total experience with social prejudice.
Total amount of stigmatization is associated with
psychological adjustment. Although obese persons in
general report more than average body dissatisfaction,
not all possess a truly negative body image.26 According to the present study, exposure to stigmatization is
related to negative body image. Negative social feedback about physical appearance in certainly likely to
increase body dissatisfaction, feelings of embarrassment about weight, and physical self-consciousness.
People who are exposed to less discrimination in their
environment may be at less risk for body image
problems. Stigmatization affects more than simply
body image, though. Self-esteem and mental health
symptoms, in general, were also associated with
exposure to stigmatization.
Because this study used a cross-sectional, correlational design, interpreting these ®ndings as evidence
that stigmatization leads to less optimal psychological
adjustment can only be speculative at this point.
Clearly, the relation could be the reverse as well,
with overweight persons who are less well adjusted
psychologically perceiving or reporting more discri-
Obesity stigmatization
A Myers and JC Rosen
mination. Longitudinal studies of stigmatization in
obesity would help to address this issue. No such
study has been conducted to date, although a prospective study of teasing did show that at least this type of
stigmatizing experience predicted negative body
image in normal and overweight adolescent girls.27
Strategies for coping with stigmatizing experiences
were wide ranging, including problem solving efforts,
confrontation, venting of emotions, social support,
cognitive modi®cation, wishful thinking, and avoidance. Coping efforts were more frequent in persons
with more stigmatizing experiences and consequently,
the relation of coping to psychological adjustment was
largely a function of the degree of stigmatization.
Coping strategies that appeared maladaptive, in that
they were associated with higher distress, involved selfcriticism and avoidance of distressing situations. These
®ndings are partially consistent with previous research
on coping, in that both self-criticism and avoidance are
forms of `disengaged' coping. However, other forms of
disengaged coping, such as ignoring negative comments, were not associated with worse adjustment.
Moreover, more positive coping strategies (including
self-acceptance, reduction of self-blame, and not hiding
oneself) were associated with more positive adjustment
on only one of the mental health indicators. Clearly,
effective coping with obesity stigmatization is an area
needing further exploration.
Overall, it seems that stigmatization triggers a great
deal of coping effort, and although no coping style is
especially positive, the absence of certain coping
responses is associated with better psychological adjustment.
It is important to note again that due to the crosssectional, correlational method of this study, no ®rm
conclusions can be made about the direction of the
relation among these variables. For instance, certain
coping styles might provoke more or less stigmatization. Also, more distressed persons might be more
likely to report certain coping responses.
Another major limitation of this study is that stigmatization was measured with a self-report inventory without any corroboration or objective evidence of the
reported experiences. In addition, although many of
the stigmatization experiences are fairly concrete (for
example, `not ®tting into seats in public') others are
merely subjective (for example, `people having low
expectations of you'). Clearly, some of the reported
stigmatizing experiences are a function of subjective
social perception in addition to factual circumstances.
Our research is further limited by the fact that,
although mild to moderately obese persons endorsed
stigmatization experiences, the initial pool of items
was generated mainly by severely obese subjects. It is
possible that different types of experiences might have
emerged from a study of mildly obese persons in the
item generation phase of the project. Moreover, the
participants in this study were mainly clinical subjects
who were seeking help for weight management. Nonclinical obesity subjects typically show less psycho-
logical distress and might report different stigmatization experiences and coping responses. Furthermore,
participants in this research were overwhelmingly
female, and thus meaningful comparisons of stigmatisation and coping employed by men as opposed to
women could not be made. Soliciting more male
participants in a future study might shed some light
on how the experience of obesity stigmatization
differs by gender. Finally, it is not clear how our
use of the internet sample may have affected the item
generation phase of this research. A literature review
yielded no controlled studies comparing respondents
to an internet questionnaire with respondents to
mailed questionnaires, although there is some evidence that internet respondents are more frequent
computer users and more knowledgeable about computers.28 Clearly, the item generation phase of our
research could have been enhanced by the use of a
more random sampling procedure.
A ®nal limitation of this research is that the
categories or themes of stigmatization and coping
did not all possess good internal consistency statistically, even though they were categorized reliably by
independent raters. Some of the low tests of internal
consistency were due to having only a couple of items
in the category. Eventually, it would be worthwhile to
perform a factor analysis on the inventories in order to
yield a statistically reliable set of subscales.
Although more research is needed on the measurement of obesity stigmatization, at this point we would
reiterate some features of our inventory that support
its validity. First, the items were nominated by obese
persons themselves and were reliable according to
independent ratings, supporting the inventory's content validity. Second, the inventory discriminated
between different levels of obesity, supporting its
construct validity as a measure of the consequences
of possessing a stigma.
Conclusion
Obesity stigmatization is a frequent and distressing
experience that requires considerable coping effort.
We have developed inventories of these two variables
that hopefully will be useful for the study of stigmatization in future research. Although many basic
questions remain about cause and effect, we believe
these inventories can also be useful clinically to help
professionals who work with obese persons to identify
stigmatizing experiences and maladaptive coping
responses in patients who may need assistance in
managing the stigma of obesity.
Acknowledgements
Appreciation to Colleen Rand and Alex M.C. MacGregor for providing assistance in recruiting subjects.
229
Obesity stigmatization
A Myers and JC Rosen
230
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