Abstract
Over the past several decades, the prevalence of overweight and obesity in children has increased considerably. While it has been widely documented that childhood obesity is related to a variety of negative health consequences, and numerous campaigns have focused on increasing physical activity and healthy food choices in children, less research has focused on the negative psychological consequences of childhood obesity, namely body image disturbance. This article examines research on body image disturbance in overweight/obese children, comorbidity of psychological disorders and childhood overweight/obesity, and factors that contribute to body image disturbance in overweight and obese youths. Additionally, the authors present research pertaining to treatment and prevention of body image disturbance in overweight/obese youths and discuss potential future directions for research, prevention and advocacy.
Weight bias and body image in overweight and obese youth
Over the past several decades, the prevalence of overweight and obesity in children has increased considerably. While it has been widely documented that childhood obesity is related to a variety of negative health consequences, such as type 2 diabetes, and cardiovascular problems (CitationFreedman et al., 2007), and numerous campaigns have focused on increasing physical activity and healthy food choices in children (see CitationThompson et al. (2006) for a review of the literature), less research has focused on the negative psychological consequences of childhood obesity, such as weight bias and body image disturbance. This article will examine research on weight bias and body image disturbance in overweight/obese children, comorbidity of psychological disorders and childhood overweight/obesity, and factors that contribute to body image disturbance in overweight and obese youth. Additionally, the authors will present research pertaining to treatment and prevention of body image disturbance in overweight/obese youth and will discuss potential future directions for research, prevention and advocacy. Because of the space constraints of this special issue, we cannot exhaustively review all of the studies in this area; therefore we will focus on the seminal studies in this area, and also selectively note review articles and the most empirically sound research articles (e.g. experimental and prospective designs).
Body image
Body image is defined as an individual's subjective evaluation of his/her own appearance (CitationThompson et al., 1999). Individuals suffering from body image disturbance often experience dissatisfaction with their weight and/or body shape (CitationSmolak & Thompson, 2009). Research indicates that young children report weight concerns and body dissatisfaction (CitationRicciardelli & McCabe, 2001; CitationSmolak & Levine, 2001), and that these concerns might be evident as early as the preschool years (CitationSmolak, 2004).
Body dissatisfaction has been linked to a number of unhealthy eating disordered behaviours such as dieting, skipping meals, fasting, self-induced vomiting, and use of diet pills or laxatives (Neumark-Sztainer et al., 2006). Body dissatisfaction is also linked to low self-esteem and depression, especially in overweight or obese youth (CitationHeinberg & Thompson, 2009; CitationSmolak & Thompson, 2009; CitationStice & Bearman, 2001).
It has been widely demonstrated that body dissatisfaction is higher in children who are overweight/obese compared to their average-sized peers (see CitationHeinberg & Thompson, 2009; CitationRicciardelli & McCabe, 2001; CitationWardle & Cook, 2005). These findings are evident in children as young as 6 years old (CitationTanofsky-Kraff et al., 2004). One study found that when controlling for both sex and race/ethnicity, weight class was the strongest predictor of body dissatisfaction in 4th–6th graders (CitationXanthopoulos et al., 2011). Other researchers have also reported that this is particularly salient in overweight/obese girls (CitationMcCabe & Ricciardelli, 2005; CitationStice, 2002; CitationThompson et al., 2007). We first begin with a brief review of the associations among body image and variables such as depression, self-esteem, and disordered eating in overweight and obese samples, then turn to the specific issue of weight bias and body image.
Body image and associated features in overweight and obesity
Extensive review of the literature indicates that children who are overweight/obese are significantly more likely to report high levels of body dissatisfaction (CitationHeinberg & Thompson, 2009; CitationSmolak & Thompson, 2009). Additionally, obesity is linked to an increased risk of negative psychosocial consequences that may also contribute to body image. Examples of such consequences include low self-esteem, depression, body dissatisfaction, and disordered eating. The following section will briefly summarize current research focusing on the link between weight status and these psychosocial factors (CitationThompson, 2004).
Self-esteem
Prospective studies have found that adiposity does predict future low self-esteem (CitationHesketh et al., 2004; CitationTiggemann, 2005), indicating that overweight/obese children may be at an increased risk for low self-esteem in the future. CitationPuhl and Latner (2007) hypothesized that variables such as weight-related teasing from peers, weight-related criticism by parents, and external control beliefs (children who believe that their weight is beyond their control) may influence the relationship between obesity and self-esteem. Therefore, it may not be weight status, per se, that influences self-esteem, but instead social factors related to weight status that may contribute to low levels of self-esteem in overweight and obese youths. Overall, findings indicate that self-esteem is moderately correlated with weight status, however, this relationship is inconsistent across studies (Wardle & Cooke, 2005). Therefore, additional research examining self-esteem and obesity is warranted.
Depression
Similar to research on self-esteem and obesity, research examining the link between depression and obesity presents mixed results. Some researchers have reported little relationship between weight status and risk for depression (CitationBrewis, 2003; CitationWardle et al., 2006), while other researchers have demonstrated that depression levels predict future obesity (CitationGoodman & Whitaker, 2002; CitationRichardson et al., 2003). CitationRingham et al. (2009) report that ‘the relationship between depression and obesity in children depends on the nature of the sample, the degree of obesity of the child, and other factors’ (p. 117). Therefore, future research is necessary in order to determine whether such a relationship does indeed exist as well as the directionality of the relationship.
Disordered eating behaviours
Research indicates that eating disordered behaviours (dieting, fasting, binging, laxatives, and diuretics) are more common in overweight and obese males and females (CitationBoutelle et al., 2002; CitationEisenberg et al., 2005; CitationNeumark-Sztainer et al., 2002b). More specifically, binge eating has been found to be both a risk factor for obesity (CitationStice et al., 1999) and a consequence of obesity (CitationFairburn et al., 1998). In a study utilizing a sample of high school females, Thompson and colleagues (2007) reported that overweight/risk of overweight participants reported receiving less anti-dieting advice (advice regarding the negative consequences of dieting and unhealthy weight control behaviours) compared to normal weight females. This may be due to the misconception that overweight individuals should engage in dieting behaviours to lose weight. They further explain that since this population of adolescents displays an elevated risk for disordered eating, if they are not provided with anti-dieting messages, they are likely to continue to participate in disordered eating rather than healthy weight control behaviours (CitationThompson et al., 2007). CitationNeumark-Sztainer et al. (2006) also found that individuals who are dissatisfied with their bodies are more likely to engage in higher levels of unhealthy eating behaviours (e.g. binge eating) and less likely to engage in healthy behaviours (physical activity and fruit and vegetable consumption). Given that overweight/obese youths demonstrate elevated levels of body dissatisfaction, these findings are particularly concerning.
Weight stigmatization, weight-related teasing, body image, psychological consequences
In an exhaustive review of the literature, CitationPuhl and Latner (2007) argue that weight stigmatization and teasing contributes to or accounts for many of the above correlates of body image in overweight and obesity. Weight stigmatization can lead to bias, prejudice, and rejection based primarily on the basis of weight class. Children, especially, are susceptible to societal pressures regarding the thin ideal and social consequences of stigmatization (CitationPuhl & Latner, 2007).
Research indicates that overweight and obese children are significantly more likely to experience societal stigmatization. CitationPuhl & Latner (2007) define weight-based stigmatization as ‘negative weight-related attitudes and beliefs that are manifested through stereotypes, bias, rejection, and prejudice towards children and adolescents because they are overweight or obese’ (p. 558). CitationBerg (2004) argues that assignment to weight categories (overweight or obese) can lead to stigmatization of children. This stigmatization against overweight individuals begins early in life. Research indicates that children as young as 3 years of age were significantly more likely to attribute negative adjectives towards overweight individuals and positive adjectives towards thin or average-sized individuals (CitationCramer & Steinwert, 1998; CitationLowes & Tiggemann, 2003). Additionally, preschoolers chose a thin or average sized playmate significantly more often than they chose an overweight playmate (CitationFrankova, 2000). More recently, CitationHarriger et al. (2010) found that preschool-age children also displayed a preference for the thin figure compared to both the average-sized and overweight figure. These findings may demonstrate preschoolers’ internalization of societal beliefs regarding anti-fat bias and the idealized thin ideal (CitationHarriger et al., 2010). Stigmatization of overweight/obese individuals can also lead to social marginalization, which is defined as social exclusion of peers as a result of viewing them as undesirable or different (CitationRobinson, 2006). CitationHaines and Neumark-Sztainer (2009) reported that qualitative interviews with overweight adolescent females demonstrated that overweight adolescents reported being treated differently than their normal weight peers.
In addition to stigmatization and social marginalization, overweight and obese youths are also at an increased risk for weight-related teasing and bullying (CitationHaines & Neumark-Sztainer, 2009). Teasing regarding body weight has been linked to body image dissatisfaction, eating disordered behaviours, low self-esteem, and negative psychological consequences such as depression and suicide ideation (CitationEisenberg et al., 2003; CitationHaines et al., 2006; CitationMenzel et al., 2010). Additionally, utilizing covariance structure modelling, it has been found that teasing about one's appearance may contribute to poor body image and disordered eating (CitationThompson et al., 1995; Citationvan den Berg et al., 2002). Overweight and obese children do not only experience weight-related stigma from their peers; research suggests that parents and educators also endorse negative stereotypes towards children (CitationPuhl & Latner, 2007). Given that the prevalence of obesity has increased dramatically throughout recent decades (CitationOgden et al., 2006), it is likely that weight stigmatization and the ensuing consequences have intensified as well (CitationPuhl & Latner, 2007).
CitationEisenberg et al. (2003) found that adolescents who reported weight-related teasing by both family members and peers reported significantly lower scores in self-esteem, depression, and suicide ideation. Interestingly, BMI was not significantly associated with any of the variables when controlling for weight-related teasing. The results of this study demonstrate that actual body weight is less related to these outcome variables, while teasing about body weight may contribute to low self-esteem and higher levels of depressive symptoms. Eisenberg et al. followed their sample for 5 years and reported that teasing at time 1 predicted levels of self-esteem and depressive symptomatology at time 2 (CitationEisenberg et al., 2006).
Treatment and prevention of body image disturbance and weight stigmatization in overweight/obese youths
Numerous initiatives have been implemented in educational, clinical, and community settings to assess, treat, and prevent overweight/obesity; however, little research has focused on strategies designed to reduce weight-stigmatization and teasing. Given that teasing and stigmatization have been shown to contribute to a number of negative psychological consequences, ‘a strong need for interventions aimed at (a) decreasing weight stigmatization by others and (b) providing support for overweight individuals facing weight stigmatization’ are needed (CitationHaines & Neumark-Sztainer, 2009, p. 87).
Interventions aimed at reducing or preventing weight stigmatization
One technique used to decrease levels of weight stigmatization is to target negative stereotypes that exist in society. Attribution theory says that attitudes towards overweight/obese individuals would be more positive if the problem is seen as beyond an individual's control (CitationWeiner et al., 1988). Therefore, if individuals believe that overweight/obesity is outside of one's control, they may not endorse negative beliefs about obese individuals. One study examined the impact of providing children with medical information to explain the cause of obesity (CitationBell & Morgan, 2000). The researchers found that presentation of this information reduced weight stigmatization in younger children but not in older children. CitationAnesbury and Tiggemann (2000) found that children who listened to a 10-minute presentation about the uncontrollability of body size did report that obesity was not under an individual's control; however, the intervention did not reduce levels of weight stigmatization. Although several studies have incorporated components of attribution theory into their intervention efforts (CitationAnesbury & Tiggemann, 2000; CitationBell & Morgan, 2000), these interventions did not significantly decrease weight-related teasing and stigmatization. Long-term interventions may prove more successful (CitationHaines & Neumark-Sztainer, 2009); therefore, additional research is needed.
One intervention programme developed by Eating Disorders Awareness and Prevention (EDAP) utilized life-sized puppets to introduce elementary school children to topics related to acceptance of diverse body sizes, positive body image, and healthy attitudes related to food (CitationIrving, 2000). Children who participated in the programme watched one or more puppet shows (one for children in grades K–3 and two for children in grades 4–5) written by a clinical psychologist. The scripts addressed acceptance of body size, dieting, and the negative consequences from teasing peers about their weight or shape. After the performance(s), children were given time to ask questions which the actual puppet characters answered. Teachers were also provided with educational information and follow-up activities for the students. In a study designed to measure the effectiveness of the EDAP puppet programme, CitationIrving (2000) found that the programme did increase acceptance of diverse body sizes and that children learned that teasing about body shape and size is hurtful. While the effects of the programme seem favourable, more research is needed to evaluate long-term results.
Haines and colleagues (2006) developed a school-based intervention programme titled Very Important Kids (VIK) in which they targeted weight stigmatization and healthy weight behaviours in elementary school children. The programme consisted of family outreach (family nights, postcards, and parent–teacher nights), school outreach (education for school personnel about weight-related teasing and a no-teasing campaign implemented in the school), an afterschool component (role plays and small group discussions centred on teasing) and a theatre production (children worked together to create a play based on personal teasing experiences). The VIK programme was effective in reducing levels of weight-related teasing in the school that received the intervention. The pilot study compared the intervention school to a control school, and results indicated that the intervention reduced levels of weight stigmatization in the intervention school. Additional research with larger numbers of schools is warranted to determine whether this intervention is successful and whether long-term results can be maintained. The initial findings are positive, and lend support to the notion that effective interventions should include individual, family, and school components (CitationHaines et al., 2006).
CitationPuhl and Latner (2007) also recommend interventions for teachers, parents, and caregivers, as well as interventions designed to target anti-fat bias in existing school curriculum designed to focus on issues regarding diversity and biases.
Prevention of childhood obesity and the role of weight stigmatization
While research has indicated that several strategies designed to prevent childhood obesity have been somewhat effective, those programmes that do not address body image can lead to negative consequences. CitationNeumark-Sztainer (2005) states that ‘there is potential for unintentional negative side effects on body image after participation in an obesity treatment or prevention program that does not address body image concerns, or even sees body dissatisfaction as a necessary motivator for change’ (p. 222). Additionally, CitationO’Dea (2005) reports that child obesity prevention programmes may lead to increased stigmatization towards overweight/obese youths and that messages focusing on the unpleasantness of being overweight may contribute to feelings of inadequacy. CitationPuhl and Latner (2007) also suggest that possible negative side effects of such interventions may include reductions in levels of self-esteem, body dissatisfaction, depression, or unhealthy exercise or eating behaviours. Given previous research, it is essential that prevention programmes should avoid placing blame on an individual for their weight, forcing children to participate in physical activities they find undesirable, and focusing on body weight (CitationO’Dea, 2005; CitationPuhl & Latner, 2007). Effective programmes should focus on healthy eating and exercise behaviours, reducing levels of stigmatization and teasing, and promotion of body-size acceptance. (CitationPuhl & Latner, 2007, p. 572) conclude that, ‘to facilitate participation in and enjoyment of health behaviors by overweight youths, program leaders must also remove blame from children who are overweight, provide education about weight bias to students and adults, and implement policies that prohibit weight-based victimization.’
Conclusions and future directions in research, treatment, and advocacy
As discussed previously, research indicates that when teasing/victimization are controlled for, weight is unrelated to negative psychological consequences. Due to this, continued assessment of these variables is warranted, as findings may inform future prevention and treatment efforts. When examining current methodology in this area of literature, several methodological issues exist (CitationPuhl & Latner, 2007). One limitation is that the majority of research relies on self-report measures. CitationPuhl and Latner (2007) argue that behavioural observations might strengthen our current understanding of stigmatization and victimization of overweight/obese youths. CitationNeumark-Sztainer and colleagues (2002a) also report that it might be possible that overweight/obese children are more sensitive to teasing compared to normal weight children, therefore inclusion of alternative measurement strategies might control for some bias present in self-report measures. Another limitation in current research is that most studies collect retrospective data, which can also be subject to bias. Researchers also argue that examination of negative stereotypes and their relationship to discriminative behaviours should be explored. Finally, they recommend further research examining different forms of victimization (physical, verbal, relational) and their relationship to negative psychological consequences (CitationPuhl & Latner, 2007).
Although research has clearly indicated that stigmatization towards overweight/obese individuals is prevalent, further research is needed to examine the consequences of teasing and stigmatization in children. Additionally, research focusing on reducing and preventing teasing and stigmatization is warranted. CitationPuhl and Latner (2007) identify a number of important domains for future research (see Table 2 in their review), and examples of topics include nature/extent of stigma, sources of stigma, psychosocial consequences of stigma, eating and other health-related behaviours, and reduction of stigma.
Weight-stigmatization and teasing have been found to account for a variety of negative health and psychological consequences in overweight/obese children. Therefore, prevention and treatment of childhood overweight/obesity should not merely focus on weight loss, but rather should include components addressing body satisfaction, healthy food and exercise behaviours, and acceptance of diverse body shapes. It is important to educate individuals, families, and school and health personnel that health is not based on weight or body size, and that weight discrimination is a serious issue requiring significant attention.
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
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