Body Image 1 (2004) 155–167

Body image and psychosocial differences among stable average

weight, currently overweight, and formerly overweight women:
the role of stigmatizing experiences
Natasha Milkewicz Annis a , Thomas F. Cash a,b,∗ , Joshua I. Hrabosky a
a Virginia Consortium Program in Clinical Psychology, Norfolk, VA, USA
b Department of Psychology, Old Dominion University, Norfolk, VA 23529, USA

Received 22 August 2003; received in revised form 31 December 2003; accepted 31 December 2003

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.
© 2004 Elsevier B.V. All rights reserved.

Keywords: Overweight; Obesity; Body image; Phantom fat; Weight stigma; Weight loss

Introduction 30.0 kg/m2 ) based on the 1999–2000 NHANES

data were 34.0% for women and 27.7% for men,
Obesity has become one of the greatest health and with the inclusion of overweight persons (body
epidemics in the world (Björntorp, 2002; Wadden, mass index = 25.0–29.9), these rates climb to 62.0
Brownell, & Foster, 2002; World Health Organization, and 67.0%, respectively (Flegal, Carroll, Ogden, &
1998). Among adults in the United States, the Johnson, 2002). During this same period, among chil-
age-adjusted rates of obesity (body mass index ≥ dren ages 6–11 years, 16.0% of boys and 14.5% of
girls were overweight, and among adolescents ages
∗ Corresponding author. Tel.: +1-757-683-4439; 12–19, 15.5% of both boys and girls were overweight
fax: +1-757-683-5087. (Ogden, Flegal, Carroll, & Johnson, 2002). These
E-mail address: [email protected] (T.F. Cash). rates reflect significant increases in the prevalence of

1740-1445/$ – see front matter © 2004 Elsevier B.V. All rights reserved.
doi:10.1016/j.bodyim.2003.12.001
156 N.M. Annis et al. / Body Image 1 (2004) 155–167

overweight or obesity relative to the NHANES data the impact of body image on daily life experiences.
from 1988 to 1994. This relationship remained even after body dissatis-
In view of Western society’s exacting standards of faction was statistically controlled.
physical appearance and its discriminatory “anti-fat” A number of risk factors contribute to, or are as-
attitudes and behaviors, it should be no surprise that sociated with, body image dissatisfaction and distress
obese individuals experience psychosocial conse- in overweight or obese individuals. Binge eating dis-
quences of their weight. Friedman and Brownell’s order (BED) has been identified as a correlate, not
(1995) meta-analysis on the psychological correlates only of body image problems, but also of a number
of obesity found few identifiable differences between of psychosocial difficulties among the obese (Mussell
obese and nonobese persons. They argued, however, et al., 1996). Overall, findings suggest that individuals
that prior research has often compared two very who binge, regardless of their weight, reveal sig-
heterogeneous populations (obese and nonobese), nificantly greater psychological distress on standard
examined only obese persons seeking weight loss, measures of psychopathology, have a more negative
used limited measures, or lacked appropriate con- body image, lower levels of self-esteem, and a higher
trols. Therefore, the conclusion of no psychosocial lifetime prevalence of psychiatric illness, particu-
differences between obese and nonobese individu- larly affective disorders (Bartlett, Wadden, & Vogt,
als may be premature (Wadden, Womble, Stunkard, 1996; Berman, Berman, Heymsfield, & Fauci, 1992;
& Anderson, 2002). Friedman and Brownell (1995, French, Jeffery, Sherwood, & Neumark-Sztainer,
2002) have concluded that obesity might cause major 1999; Webber, 1994). Although the Diagnostic and
psychological difficulties for some individuals, mild Statistical Manual of Mental Disorders (DSM-IV-TR;
problems in some, and perhaps no distress in others. American Psychiatric Association, 2000) does not in-
One of the most reliable psychological correlates of clude body image disturbance as a criterion for BED,
overweight and obesity is body dissatisfaction (Cash researchers argue that significantly elevated levels of
& Roy, 1999; Friedman & Brownell, 1995; Sarwer, dysfunctional body image attitudes regarding weight
Wadden, & Foster, 1998; Schwartz & Brownell, 2002, and shape are a major characteristic of the disorder
2004). If an individual’s social environment regards (Cargill, Clark, Pera, Niaura, & Abrams, 1999; Grilo,
her or him as unattractive, it should not be surpris- 2002). It appears, therefore, that body image and
ing that the obese individual will internalize this binge eating are associated.
self-view. Although obese individuals may or may not A second possible risk factor for increased body
be more likely to distort their body size (Schwartz & dissatisfaction in obese individuals is the stigma and
Brownell, 2004), they are more dissatisfied with their discrimination that they experience in their daily
appearance and are more avoidant of social situations lives (Neumark-Sztainer & Haines, 2004). As the
in comparison to nonobese people (Rosen, 2002; rates of overweight and obesity in the United States
Sarwer et al., 1998; Schwartz & Brownell, 2004). are rapidly increasing, Western society perpetuates
Within the overweight and obese population, as well messages that being thin means being beautiful and
as within the general public, women are more likely successful in many areas of life (Jackson, 2002;
to express body dissatisfaction and distress than their Tiggemann, 2002). In contrast, being overweight
male counterparts (Cash & Roy, 1999; Schwartz & connotes ugliness, morbidity, laziness, and personal
Brownell, 2002, 2004). A negative body image can failing (Puhl & Brownell, 2001, 2002). Such negative
have adverse psychosocial consequences, including attitudes have come to be “one of the last socially ac-
disordered eating (Cash & Deagle, 1997; Stice, 2002), ceptable forms of discrimination” (Puhl & Brownell,
depression (Noles, Cash, & Winstead, 1985), social 2002, p. 108). Stigma and discrimination can be found
anxiety (Cash & Fleming, 2002a), impaired sexual in a wide range of life domains, including employ-
functioning (Wiederman, 2002), and poor self-esteem ment (Pingitore, Dugoni, Tindale, & Spring, 1994;
(Powell & Hendricks, 1999). Cash and Fleming Roehling, 1999), medical and health care (Foster
(2002b) and Cash, Jakatdar, and Williams (in press) et al., 2002; Harvey & Hill, 2001; Hebl & Xu, 2001;
found an inverse relationship between women’s body Price, Desmond, Krol, Snyder, & O’Connell, 1987),
mass and body image quality of life, which refers to and formation of relationships in childhood (Anesbury
 N.M. Annis et al. / Body Image 1 (2004) 155–167 157

& Tiggemann, 2000; Bell & Morgan, 2000; Cramer dissatisfaction despite weight loss (Adami et al.,
& Steinwart, 1998). Prejudice against obese individ- 1998; Adami, Meneghelli, Bressani, & Scopinaro,
uals begins at a young age and lasts throughout the 1999; Cash, Counts, & Huffine, 1990). Formerly,
lifespan. For instance, Cramer and Steinwart (1998) overweight individuals’ greater body image concerns
found that preschool children endorsed a negative compared to weight-matched, never-overweight indi-
stereotype about fat persons, and that as children viduals evinces this phenomenon. On the other hand,
grow older their negative beliefs strengthen. Col- some research has not confirmed phantom fat, such
lege students have described obese people as more that formerly overweight individuals reported body
self-indulgent, less self-disciplined, and less attrac- satisfaction equivalent to average-weight controls
tive than average weight individuals (Lewis, Cash, (Cash, 1994; Foster et al., 1997). The current study
Jacobi, & Bubb-Lewis, 1997), stereotypes that tend to reexamines this issue.
be shared by overweight persons themselves (Lewis The purpose of this research was to examine and
et al., 1997; Tiggemann & Rothblum, 1988). compare body image and psychosocial functioning
Some overweight or obese individuals face difficul- among three groups of women. Only women were
ties in their abilities to function in interpersonal situ- studied given the evidence that, relative to men, they
ations. Recreational activities may be constrained due are at greater risk for psychosocial difficulties when
to physical discomfort or social rejection (Lean, Han, overweight (Cash & Roy, 1999; Friedman & Brownell,
& Seidell, 1999; Myers & Rosen, 1999). Although 1995). Three nonclinical cohorts were studied: (a) now
Berman et al. (1992) found that a significant number overweight (NOW) individuals, defined as women
of treatment-seeking obese individuals were limited or who have been overweight for at least the past 3 years;
isolated in their social relationships, Miller, Rothblum, (b) formerly overweight (FOW) individuals, who
Brand, and Felicio (1995) discovered that obese and were overweight at some time in their life for at least
nonobese women did not differ in social competence, 6 months, excluding pregnancy, and have been aver-
social network size, or perceived social support from age weight for the past 2 or more years; and (c) stable
friends and family. Obesity may reduce opportuni- average weight (SAW) individuals, who have main-
ties for dating and marriage, especially among women tained an average weight throughout their lifetime.
(Gortmaker, Must, Perrin, Sobol, & Deitz, 1993; Stake These groups were assessed on dimensions of body
& Laurer, 1987). Finally, Cash, Beskin, and Yamamiya image, self-esteem, social anxiety, depression, eating
(2001) found that weight was modestly positively re- behaviors, quality of life, and perceived weight-related
lated to physical self-consciousness during sex among stigmatization. We sought to answer these empirical
college women. questions: Do SAW and FOW women report signif-
Quality of life seems to improve after weight loss, icantly better body image, self-esteem, eating behav-
including an increase in social and physical activ- iors, affect, and quality of life compared to women
ities (Isacsson, Frederiksen, Nilsson, & Hedenbro, who are currently overweight (NOW)? Furthermore,
1997), better relationships with others, including to examine the phantom fat phenomenon, what are the
spouses (Chandarana, Conlon, Holliday, & Deslippe, differences between weight-matched SAW and FOW
1990), better body image (Cash, 1994; Foster, women? Finally, among NOW and FOW women, is
Wadden, & Vogt, 1997), and improved sexual func- weight-related stigmatization associated with current
tioning (Chandarana et al., 1990). Although these body image and psychosocial functioning?
findings suggest that quality of life may be impaired
in overweight or obese persons, studies are based
on clinical samples seeking weight loss, are some- Method
times retrospective, and are far from comprehensive
in tapping all facets of quality of life. Participants and recruitment
While weight loss may lead to increased body
satisfaction, some formerly overweight persons may The sample consisted of 165 women from commu-
also experience “phantom fat”, whereby they remain nity (n = 65) and university populations (n = 100),
weight-concerned and retain some degree of body both from the mid-Atlantic region of the United States.
158 N.M. Annis et al. / Body Image 1 (2004) 155–167

Participants were 18 years of age or older. College (based on BMIs for adolescence and adulthood and
participants responded to announcements posted on on self-labeled “overweight” and figural choices for
the campus, and community participants responded to childhood). SAW included 65 women who had main-
flyers posted at local exercise facilities and advertise- tained an average weight throughout their lifetime.
ments in local print media and on the internet. The lat- Among NOW participants, 17% were overweight
ter was posted on a Weight Watchers website, which and 83% were obese (BMI: M = 36.8, SD = 8.1).
produced only five participants. Weight was not ex- BMIs of the SAW group ranged from 19.0 to 24.9
plicitly mentioned in advertisements. College students (M = 21.7, SD = 1.7), and BMIs of the FOW group
received extra credit in their courses for participation. ranged from 18.7 to 24.8 (M = 22.1, SD = 1.9).
Community volunteers were eligible to win one of Histories indicated that 67% of the FOWs and 62%
nine raffle prizes from $25 to $100. of the NOWs were overweight as children, and 67%
Participants’ ages ranged from 18 to 81 (M = 30.4, of FOWs and 78% of NOWs were overweight as
SD = 14.0). Regarding ethnicity, 70% of participants adolescents. Chi-square analyses indicated that these
were European American, 20% African American, 6% were not significant differences. Whereas by defini-
Asian, 2% Hispanic, and the remaining 2% were of tion 100% of NOW women were overweight as adults,
other or unspecified ethnicity. Seventy-seven percent this was true of 45% of FOW women. Finally, 21%
of participants completed or were in the process of of FOW participants had been overweight during all
completing college, 9% completed or were in the pro- three periods, and this was the case for 57% of the
cess of completing graduate school, and 13% com- NOW group, χ2 (1) = 12.58, p < 0.001.
pleted high school only. One-half of participants were
single, 21% were cohabitating or married, and 16%
Procedures and assessments
were separated, divorced, or widowed.
After an informed consent procedure, participants
Classification of weight groups
anonymously completed a battery of standardized
measures of body image and psychosocial function-
Participants were ultimately classified as either
ing, as well as a demographic and weight history
currently overweight (NOW), formerly overweight
form. College participants returned materials to an
(FOW), or stable average weight (i.e. never over-
on-campus office; community participants mailed
weight). Current body mass index (BMI, kg/m2 ) was
them in a pre-stamped envelope.
calculated based on self-reported height and weight.
Average weight is defined as a BMI between 18.5 and
24.9; overweight is a BMI from 25.0 to 29.9; and obe- Multidimensional Body-Self Relations Questionnaire
sity is defined as a BMI of 30.0 or higher (Björntorp, (MBSRQ)
2002). Participants completed a weight history ques- The MBSRQ is an attitudinal body image assess-
tionnaire that obtained height, lowest weight and ment, using a 5-point disagree–agree response format
duration, and highest weight and duration. To supple- (Brown, Cash, & Mikulka, 1990; Cash, 2004). This
ment these data, participants were asked whether and study used three MBSRQ appearance subscales: The
when they had been overweight by at least 10 pounds 7-item Appearance Evaluation subscale assesses pos-
(excluding pregnancy) and completed figural rating itive and negative appraisals of one’s physical appear-
scales for largest body size. Because recollections of ance. Its reliability (Cronbach’s alpha) in this sample
height and weight from childhood are apt to be unre- was 0.92. The 4-item Overweight Preoccupation sub-
liable, we used Collins’s (1991) seven figural stimuli scale assesses fat anxiety, weight vigilance, dieting,
for childhood (age 4 to pre-puberty), with figures 5, 6, and eating restraint, with an internal consistency of
and 7 reflecting “overweight”. Being NOW required 0.72 in this study. The 9-item Body Areas Satisfaction
a BMI ≥ 25.0 for at least the past 3 years (n = 58). Scale (BASS) measures the degree of dissatisfaction
There were 42 FOW women who had been average or satisfaction with specific body areas and attributes
weight for the past 2 or more years but were over- (e.g., face, weight, muscle tone, etc.). Its internal con-
weight for at least 6 months at some previous time sistency was 0.84.
 N.M. Annis et al. / Body Image 1 (2004) 155–167 159

Situational Inventory of Body Image Dysphoria Extended Satisfaction With Life Scale (ESWLS)
(SIBID) The 50-item ESWLS developed by Alfonso,
The SIBID (Cash, 2002, 2004) is a 48-item measure Allison, and Rader (1996) assesses satisfaction within
that assesses negative body image emotions in various nine domains of life: general life, social life, sexual
situational contexts. For each item, participants rate life, relationship, self, physical appearance, family
the frequency of dysphoric emotions on a 5-point scale life, school life, and job satisfaction. Each subscale
ranging from 0 (“Never”) to 4 (“Always or Almost contains five items, with the exception of the 10-item
Always”). Its internal consistency was 0.98. job satisfaction subscale. Each item is rated on a
7-point Likert-type scale, ranging from 1 (“strongly
disagree”) to 7 (“strongly agree”). The ESWLS de-
Appearance Schemas Inventory (ASI)
rives an overall composite score. Items that were not
The ASI (Cash & Labarge, 1996) is a 14-item mea-
applicable (e.g., for unemployed persons or those
sure assessing dysfunctional body image investment
not in school) were prorated (i.e., mean of answered
surrounding the meaning and importance of one’s
items X 50). The measure’s internal consistency in
physical appearance (e.g. “I should do whatever I
this sample was 0.94.
can to always look my best.” “What I look like is
an important part of who I am.”). Participants rate
Binge Eating Scale (BES)
items on a 5-point disagree–agree scale. Its internal
The BES (Gormally, Black, Daston, & Randin,
consistency in this sample was 0.87.
1982) is a 16-item scale designed to assess binge
eating feelings, cognitions, and behavioral manifes-
Texas Social Behavior Inventory (TSBI) tations (e.g., preoccupation with restraint of eating,
The TSBI (Helmreich & Stapp, 1974) is a 16-item guilt, eating in secret, eating fast). For each item, par-
measure of social self-esteem. Participants rated a se- ticipants choose one of three or four response options
ries of self-statements on a 5-point scale from 0 (“not that best describes their eating-behavior experience.
at all characteristic of me”) to 4 (“very characteristic Its internal consistency was 0.92.
of me”). High composite scores (summed items) in-
dicate positive social self-esteem. Its internal consis- Stigmatizing Situations Questionnaire—Extended
tency was 0.85. (SSQ-E)
This SSQ (Myers & Rosen, 1999) was adapted and
expanded for this current study. The original SSQ
Fear of Negative Evaluation—short form (Brief FNE)
contained 50 items for overweight stigma experienced
The Brief FNE is a 12-item measure of anxiety
during adulthood. We dropped two items that were
in anticipation of being evaluated negatively by oth-
related to childhood stigma. Our expansion contained
ers (Leary, 1983). Participants rate themselves on a
53 items for overweight stigma during adolescence
scale from 1 (“not at all characteristic of me”) to 5
and 25 items for stigma during childhood. Exemplary
(“extremely characteristic of me”), with higher scores
items are: “Being called names, laughed at, or teased
reflecting greater social-evaluative anxiety. The Brief
by your peers.” “Being excluded from extracurricular
FNE had an internal consistency of 0.92 in the current
activities . . . because of your weight.” “Losing a job
sample.
because of your size.” “Being stared at in public.”
“Not being able to find clothes that fit.” Thus, the
Center for Epidemiological Studies—Depressed extended 126-item measure assesses stigmatizing
Mood Scale (CES-D) situations encountered and the emotional impact of
The CES-D (Radloff, 1977) is a 20-item measure these in adulthood, adolescence, and childhood. Items
of depressive symptomatology during the past week, reflected themes of fat stigmatization rated from 0
rated on a Likert-type scale, ranging from 1 (“rarely (“never occurred”) to 9 (“occurred daily”) and the
or none of the time, or less than 1 day”) to 4 (“most or emotional impact of each situation rated from 0 (“not
all of the time, or 5–7 days”). Its internal consistency upsetting”) to 4 (“very upsetting”). The original SSQ
was 0.89. was reliable (α = 0.95) and discriminated between
160 N.M. Annis et al. / Body Image 1 (2004) 155–167

severely obese and mild to moderately obese per- [χ2 (2, N = 163) = 7.34, p < 0.05], understandably
sons (Myers & Rosen, 1999). We calculated a stigma because the NOW women were older.
frequency score and a stigma impact score. Because
these two scores were highly correlated (rs ranged Body mass index
from 0.88 to 0.90), we analyzed only the stigma
frequency index. Internal consistency of the scales A GLM ANOVA on BMI indicated a significant dif-
measuring stigma in childhood, adolescence, and ference among groups [F(2, 162) = 164.7, p < 0.01,
adulthood were 0.94, 0.95, and 0.94, respectively. η2 = 0.67]. Post-hoc analyses revealed that, as in-
tended, NOW participants were significantly heavier
Demographic and historical data sheet than FOW and SAW participants. There was no dif-
This form obtained information on age, ethnicity, ference between FOW and SAW participants. Group
marital status, education, height, weight, and weight means and standard deviations were provided previ-
history (described previously). ously.

Differences in body image

Results
A composite score was computed based on
participants’ averaged normalized (z) scores on three
Preliminary analyses
moderately to highly correlated variables: the MB-
SRQ Appearance Evaluation subscale, Body Areas
Prior to performing inferential analyses, we ex-
Satisfaction scale, and the reverse-scored SIBID. This
amined whether their assumptions were met. All
composite score reflects participants’ reported dissat-
dependent variables were normally distributed. The
isfaction with their appearance, as well as the body
assumption of homogeneity of variance was slightly
image distress felt across various situations. Lower
violated in a few analyses; however, analysis of vari-
values reflect greater dissatisfaction and distress.
ance (ANOVA) is robust to this violation if there are
The GLM ANOVA on this body image index indi-
no outliers and sample sizes are relatively large and
cated a significant difference among the three groups
equal (Tabachnick & Fidell, 2001). Post-hoc Tukey
(p < 0.001). As shown in Table 1, NOW participants
HSD tests were performed if the overall ANOVA for
had significantly lower scores than the FOW and
the group comparisons for each scale was significant
SAW groups, suggesting appreciably greater body
(p < 0.05).
image dissatisfaction/distress among NOW women
General-linear-model (GLM) one-way between-
(p < 0.001). The FOW group had a marginally poorer
groups ANOVAs were performed on continuous de-
body image relative to the SAW group (p < 0.08).
mographic variables. There was a significant differ-
ANOVAs also indicated that both NOW and FOW
ence in age among the three groups [F(2, 162) = 7.35,
participants experienced significantly greater over-
p < 0.01]. Post-hoc tests revealed that NOW group
weight preoccupation (MBSRQ) and dysfunctional
participants (M = 35.8, SD = 14.8) were signifi-
appearance investment (ASI) than did the SAW group
cantly older than FOW (M = 28.4, SD = 12.8) and
(ps < 0.001). NOW and FOW women did not differ.
SAW (M = 26.9, SD = 12.7) participants.1 There
were no significant educational differences among
Differences in psychosocial functioning
the groups. Chi-square tests compared groups on
nominal demographic variables. They did not differ
Table 1 further summarizes results of ANOVAs on
in ethnicity; however, the NOW women were more
self-esteem, social anxiety, depression, quality of life,
likely to be married than were FOW and SAW women
and binge eating. NOW participants reported poorer
social self-esteem than SAW participants (p < 0.05),
1 The study’s principal analyses were also conducted by con- and reported less overall satisfaction with their life and
trolling for age as a covariate. As results were not substantively more symptoms of binge eating than both FOW and
altered, only the uncontrolled analyses are reported. SAW participants (ps < 0.001), who did not differ.
 N.M. Annis et al. / Body Image 1 (2004) 155–167 161

Table 1
Comparison of groups on body image and psychosocial functioning
Measures M (SD) F-value Effect size
(partial η2 )
Currently Formerly Stable average
overweight overweight weight
Body image
Body image dissatisfaction/distress −0.74 (0.70) a 0.20 (0.81) b 0.51 (0.68) b 48.63∗∗ 0.38
Overweight preoccupation 3.15 (0.86) a 3.36 (0.92) a 2.62 (1.03) b 8.98∗∗ 0.10
Dysfunctional appearance investment 2.98 (0.63) a 2.79 (0.70) a 2.45 (0.64) b 10.37∗∗ 0.12
Psychosocial functioning
Social self-esteem 52.9 (10.1) a 54.1 (8.7) ab 57.0 (8.9) b 3.22∗ 0.04
Social anxiety 37.9 (11.7) 36.3 (11.0) 34.1 (9.4) 1.99 0.02
Depression 16.7 (9.8) 16.9 (10.4) 13.5 (9.9) 2.10 0.03
Life satisfaction 188.1 (54.8) a 238.8 (36.1) b 248.5 (31.5) b 33.73∗∗ 0.30
Binge eating 19.03 (10.4)a 8.79 (8.14) b 9.59 (8.85) b 20.89∗∗ 0.21
Means that do not share a common letter are significantly different.
∗ p < 0.05.
∗∗ p < 0.001 (df = 2, 158–162).

There were no significant group differences in social Relationship between perceived stigmatization and
anxiety (p = 0.14) or depressive symptoms (p = body image
0.13).
Pearson correlations between perceived stigmatiza-
Differences in perceived stigmatization tion and body image are reported in Table 2. For the
NOW group, childhood, adolescent, and adulthood
ANOVAs compared NOW and FOW groups on stigmatization were all significantly related to greater
childhood, adolescent, and adulthood overweight body image dissatisfaction/distress (at least p < 0.01),
stigmatization. Sample sizes varied across analyses more dysfunctional appearance investment (at least
because participants completed the measure only for p < 0.01), and more overweight preoccupation (at
the period(s) in which they were overweight. The least p < 0.05). For the FOW group, there were no re-
absence of significant differences between NOW liable relationships between stigmatization at any pe-
and FOW groups indicated that currently overweight riod and the three body image measures. Of course, the
women experienced as much stigmatization at each very small sample size of FOW women overweight as
period as their formerly overweight peers. adults precludes detection of significant associations.

Table 2
Pearson correlations between stigmatization history and body image
Body image measures Childhood stigmatization Adolescent stigmatization Adulthood stigmatization

NOW (n) FOW (n) NOW (n) FOW (n) NOW (n) FOW (n)

Body image dissatisfaction/distress −0.58∗∗ (31) −0.34 (28) −0.53∗∗ (30) 0.14 (26) −0.56∗∗∗ (51) 0.06 (13)
Overweight preoccupation 0.48∗∗ (31) 0.26 (28) 0.36∗ (30) 0.14 (26) 0.50∗∗∗ (51) 0.03 (13)
Dysfunctional appearance investment 0.53∗∗ (30) 0.21 (28) 0.55∗∗ (29) 0.13 (25) 0.39∗∗ (50) 0.33 (12)
∗ p < 0.05.
∗∗ p < 0.01.
∗∗∗ p < 0.001.
162 N.M. Annis et al. / Body Image 1 (2004) 155–167

Table 3
Pearson and partial correlations between stigmatization and psychosocial functioning
Psychosocial functioning measures Childhood stigmatization Adolescent stigmatization Adulthood stigmatization

NOW (n) FOW (n) NOW (n) FOW (n) NOW (n) FOW (n)

Social self-esteem
Pearson r −0.40∗ (29) −0.45∗ (26) −0.46∗ (28) 0.26 (24) −0.32∗ (49) 0.12 (11)
Partial r −0.19 (28) −0.39∗ (25) 0.29 (27) 0.23 (23) −0.11 (48) 0.10 (10)
Social anxiety
Pearson r 0.62∗∗∗ (29) 0.46∗ (26) 0.59∗∗ (28) −0.17 (24) 0.44∗∗∗ (49) −0.05 (11)
Partial r 0.46∗∗ (28) 0.35 (25) 0.44∗ (27) −0.12 (23) 0.22 (48) −0.03 (10)
Depression
Pearson r 0.45∗ (29) 0.18 (26) 0.51∗∗ (28) 0.05 (24) 0.37∗∗ (49) 0.21 (11)
Partial r 0.33 (28) 0.04 (25) 0.42∗ (27) 0.12 (23) 0.23 (48) 0.25 (10)
Life satisfaction
Pearson r −0.53∗∗ (28) −0.04 (26) −0.53∗∗ (27) −0.15 (24) −0.43∗∗ (48) −0.02 (10)
Partial r −0.38∗ (27) −0.02 (25) −0.40∗ (26) −0.16 (23) −0.26 (47) −0.03 (9)
Binge eating
Pearson r 0.54∗∗ (29) 0.06 (26) 0.59∗∗∗ (28) −0.06 (24) 0.54∗∗∗ (49) 0.32 (11)
Partial r 0.22 (28) −0.03 (25) 0.35 (27) −0.03 (23) 0.21 (48) 0.35 (10)
Partial correlations controlled for the body-image composite score.
∗ p < 0.05.
∗∗ p < 0.01.
∗∗∗ p < 0.001.

Relationship between perceived stigmatization and for body dissatisfaction/distress. Table 3 presents the
psychosocial functioning results. For the NOW group, childhood stigmatization
remained significantly related to more social anxiety
Pearson correlations between perceived stigma- (p < 0.01) and poorer quality of life (p < 0.05).
tization and psychosocial functioning are given in Adolescent stigmatization remained significantly as-
Table 3. For the NOW group, stigmatization at all sociated with lower quality of life and higher levels of
periods was significantly related to all psychosocial social anxiety and depressive symptoms (ps < 0.05).
adjustment indices. Childhood, adolescent, and adult- However, stigmatization in adulthood was no longer
hood stigmatization were related to lower self-esteem related to any of the psychosocial adjustment variables
(at least p < 0.05), greater social anxiety (at least nor to social self-esteem or binge eating at any pe-
p < 0.01), more depression (at least p < 0.05), less riod. For the FOW group, childhood stigmatization re-
life satisfaction (ps < 0.01), and more binge eating mained significantly related to lower self-esteem (p <
(at least p < 0.01). For the FOW group, childhood 0.05), but was not correlated with any other mea-
stigmatization was related to lower social self-esteem sures. Adolescent and adulthood stigmatization were
(p < 0.05) and higher social anxiety (p < 0.05), but still uncorrelated with the psychosocial functioning
was not correlated with depression, satisfaction with measures.
life, or binge eating. There were no significant rela-
tionships between adolescent or adult stigmatization
and any measure of psychosocial functioning of the Discussion
FOW women. Again, adulthood observations were
too few to be reliable. Excessive weight can lead to increased risk of a
To determine if perceived stigmatization is related variety of medical conditions, ranging from diabetes
to psychosocial adjustment independent of body im- mellitus to cardiovascular disease (Pi-Sunyer, 2002).
age, partial correlations were computed, controlling Yet it is obesity’s potential psychosocial consequences
 N.M. Annis et al. / Body Image 1 (2004) 155–167 163

and vulnerabilities that are less understood. These of their former obesity, such as flabby skin, wrinkles,
vulnerabilities stem from numerous risk factors, in- or cellulite (Sarwer & Thompson, 2002). Heinberg,
cluding the stigma associated with overweight and Thompson, and Matzon (2002) have also argued that
obesity (Cash & Roy, 1999; Puhl & Brownell, 2001, some moderate level of body image concern may
2002). To evaluate the nature and scope of psychoso- adaptively motivate weight loss (and maintenance).
cial difficulties associated with being overweight In the face of improved body satisfaction, perhaps
or obese, we compared three nonclinical groups of continued weight vigilance and some anxiety about
women who were currently overweight (NOW), for- becoming fat (again) may promote healthy eating
merly overweight during childhood, adolescence, or and exercise behaviors in the prevention of weight
adulthood (FOW), or never overweight (SAW). The regain.
majority (83%) of the NOW women were obese. The Studies comparing obese and nonobese individu-
SAW and FOW groups had an equivalent current als on measures of social anxiety, depression, and
BMI. The three groups were compared on measures self-esteem have often found no differences (Friedman
of body image, social self-esteem, social anxiety, & Brownell, 1995). However, many of these stud-
depression, quality of life, and binge eating. ies were poorly designed and consisted only of
Congruent with previous research (for reviews, see treatment-seeking patients. The current research used
Cash & Roy, 1999; Schwartz & Brownell, 2002, 2004) established measures of psychosocial functioning and
and predicted findings, NOW women reported greater life satisfaction and also included a formerly over-
body dissatisfaction and distress than either FOW or weight group. Results indicated no group differences
SAW women, with the FOW group experiencing a on social anxiety or depression, suggesting obesity
marginally (p < 0.08) poorer body image than the alone does not heighten the risk of these difficulties.
SAW group. FOW and NOW women did not dif- However, NOW women reported significantly poorer
fer in extent of overweight preoccupation or dysfunc- social self-esteem than did SAW women, and FOW
tional appearance investment. However, both groups women did not differ from either NOW or SAW
reported greater overweight preoccupation and dys- women, suggesting that social self-esteem may be
functional investment than did SAW women who had partially restored with moderate weight loss.
never been overweight. These findings suggest that Currently overweight women reported significantly
while formerly overweight women may not continue more binge eating pathology relative to both FOW
to suffer from significant dissatisfaction or distress and SAW women, who did not differ. Our expected
about their appearance, possibly because they have finding of more binge eating among NOW women
lost weight, preoccupation about their weight and ap- is consistent with evidence they are more likely
pearance persists. to engage in binge eating than nonobese individ-
Thus, our results provide clarifying evidence of uals (Schwartz & Brownell, 2004; Smith, Marcus,
“phantom fat” in formerly overweight women (Adami Lewis, Fitzgibbon, & Schreiner, 1998; Telch, Agras,
et al., 1998, 1999; Cash et al., 1990; Foster & Matz, & Rossiter, 1988; Wilfley, Wilson, & Agras, 2003;
2002), and begin to shed light into the specific dif- Womble et al., 2001).2 Our FOW participants may
ficulties these women endure. At least 2 years after have engaged in less binge eating prior to and after
losing weight, these women no longer appear to be weight loss, therefore enabling these women to lose
so dissatisfied with their body, but still are signifi- weight and maintain weight loss.
cantly cognizant of and anxious about their weight
and hold schematic beliefs about salience or influence 2 To provide supplementary evidence of the relations between
of their appearance in their lives. Whereas sustained binge eating and body image and psychosocial functioning among
weight loss brings more body image satisfaction (see overweight women, we calculated Pearson’s correlations with the
Foster & Matz, 2002; Sarwer & Thompson, 2002), BES. Among NOW participants, binge eating was related to greater
perhaps the threat of weight gain and the past expe- body-image dissatisfaction/distress (r = −0.71, p < 0.001), dys-
functional appearance investment (r = 0.42, p < 0.001), poorer
riences of social adversities do not completely dis- social self-esteem (r = −0.51, p < 0.001), greater social anxiety
sipate. Moreover, for those who have lost very large (r = 0.49, p < 0.001) and depression (r = 0.47, p < 0.001), and
amounts of weight, the body may possess reminders less satisfaction with life (r = −0.37, p < 0.005).
164 N.M. Annis et al. / Body Image 1 (2004) 155–167

In addition to assessing for pathology, we exam- functioning among formerly overweight women.
ined life satisfaction or “quality of life” across a range Those who experienced more stigma in childhood
of domains (i.e., general, social, sexual, self, appear- also reported poorer social self-esteem and greater so-
ance, family, relationship, school, and work). NOW cial anxiety. These data suggest that after a period of
women reported a poorer quality of life relative to sustained weight loss, past experiences of stigma may
both the FOW and SAW women, who did not differ. have less bearing on one’s body image and psychoso-
This was the largest effect size among the psychoso- cial functioning. In effect, successful weight loss
cial functioning measures (partial η2 = 0.30), second may trump many of these stigmatizing experiences,
only to body image dissatisfaction/distress (partial whereas among women who remain overweight, such
η2 = 0.38). These findings may reflect the greater ad- experiences continue to impact their psychological
versities that overweight or obese women encounter well-being. Perhaps this is because currently over-
in their daily lives. Although this is a cross-sectional weight persons continue to experience social stigma,
study, the results for the FOW group may indicate that which activates their emotion-laden schemas about
when overweight women successfully lose weight their body, whereas those who have lost weight no
and maintain the loss, they experience an increase in longer have to deal with intolerance in their environ-
overall quality of life. ment and may actually receive positive reinforcement
Another purpose of our study was to examine the (e.g., compliments, support, new clothes, etc.) for
moderating role of stigmatizing experiences on the their thinner body type.
body image and psychosocial functioning of over- To clarify the relationship between stigmatization
weight and formerly overweight persons. We adapted and psychosocial functioning, apart from body image
the Stigmatizing Situations Questionnaire (Myers & disparagement, we computed partial correlations con-
Rosen, 1999) to assess the frequency of perceived trolling for body image dissatisfaction/distress. For
stigma during overweight periods in childhood, ado- NOW women, childhood stigmatization remained sig-
lescence, and adulthood. No differences were found nificantly related to social anxiety and quality of life,
between NOW and FOW groups, at any period, indi- and adolescent stigmatization was still associated with
cating equivalent degrees of stigma when overweight, depression, social anxiety, and quality of life. None of
regardless of current weight. Findings for the NOW the psychosocial functioning measures remained re-
group overwhelmingly supported our hypothesis that lated to adult stigma. Our findings suggest that stigma-
stigmatization history would be associated with cur- tizing experiences in childhood and adolescence may
rently greater body image disturbance. More perceived be internalized for long periods of time and may have
stigma in childhood, adolescence, and adulthood was a lasting impact on functioning in adulthood among
moderately related to greater body image dissatisfac- overweight women, regardless of their body satisfac-
tion/distress, weight preoccupation, and dysfunctional tion or dissatisfaction. For the FOW group, after con-
beliefs about appearance. Moreover, as hypothesized, trolling for body image, the significant relationship
among NOW women, stigmatizing experiences at between childhood stigmatization and poorer social
each period were associated with currently lower self-esteem remained. The FOW group reported stig-
social self-esteem and life satisfaction, and greater matizing experiences comparable to the NOW women
social anxiety, depression, and binge eating. Although throughout life, yet seemed to be largely unaffected
we cannot infer causality, stigmatization does show a by these experiences after weight loss. Perhaps the re-
consistent relationship to lower levels of functioning duction of weight-related stigma in their current lives
among NOW women (Neumark-Sztainer & Haines, reduces the impact of past prejudice and discrimina-
2004). tion.
These findings for the NOW group stand in marked Despite its strengths and contributions to the liter-
contrast to those for the FOW group, for whom stigma ature, this research is not without limitations. Given
history and current body image were unrelated (al- its cross-sectional design, we cannot reach causal
though small sample size prevents a conclusion for conclusions that losing weight is responsible for
adulthood stigma). Only two significant correlations the observed differences between currently and for-
occurred between stigmatization and psychosocial merly overweight women. Group classifications were
 N.M. Annis et al. / Body Image 1 (2004) 155–167 165

derived in part from recollections of body size rather Alfonso, V. C., Allison, D. B., & Rader, D. E. (1996). The extended
than from objective historical data. Prospective re- satisfaction with life scale: Development and psychometric
properties. Social Indicators Research, 38, 275–301.
search is needed to elucidate the findings of this study. American Psychiatric Association. (2000). Diagnostic and
Reports of stigmatization are retrospective and could statistical manual of mental disorders (4th ed., Text Revision).
be autobiographically biased, although it is reassuring Washington, DC: American Psychiatric Association.
that NOW and FOW groups did not differ in their Anesbury, T., & Tiggemann, M. (2000). An attempt to reduce
reports. Furthermore, as indicated, the number of negative stereotyping of obesity in children by changing
controllability beliefs. Health Education Research, 15, 145–
observations in some analyses had diminished power.
152.
Our research provides clear evidence that the great- Bartlett, S. J., Wadden, T. A., & Vogt, R. A. (1996). Psychosocial
est difference between overweight women and those consequences of weight cycling. Journal of Consulting and
who were previously or never overweight is a more Clinical Psychology, 64, 587–592.
negative body image and a poorer quality of life. Bell, S. K., & Morgan, S. B. (2000). Children’s attitudes and
behavioral intentions toward a peer presented as obese: Does a
Further, it suggests that the cumulative prejudice and
medical explanation for the obesity make a difference? Journal
discrimination that overweight persons face in their of Pediatric Psychology, 25, 137–145.
lives is negatively related to their well-being. Unfor- Berman, W. H., Berman, E. R., Heymsfield, S., & Fauci, M.
tunately, most weight management programs do not (1992). The incidence and comorbidity of psychiatric disorders
systematically evaluate or address body dissatisfaction in obesity. Journal of Personality Disorders, 6, 168–175.
(Rosen, Orosan, & Reiter, 1995) or stigmatization, Björntorp, P. (2002). Definition and classification of obesity. In C.
G. Fairburn & K. D. Brownell (Eds.), Eating disorders and
despite the fact that effective cognitive-behavioral obesity: A comprehensive handbook (2nd ed., pp. 377–381).
body image treatments are available (Cash & New York: Guilford Press.
Hrabosky, 2004; Cash & Strachan, 2002). Recently, Brown, T. A., Cash, T. F., & Mikulka, P. J. (1990). Attitudinal
some clinical researchers have been incorporat- Body-Image Assessment: Factor analysis of the body-self
ing such procedures in their programs (Cooper & relations questionnaire. Journal of Personality Assessment, 55,
135–144.
Fairburn, 2002; Foster et al., 1997). Addressing body Cargill, B. R., Clark, M. M., Pera, V., Niaura, R. S., & Abrams,
image disparagement in weight management programs D. A. (1999). Binge eating, body image and depression and
may help reduce maladaptive weight preoccupation self-efficacy in an obese clinical population. Obesity Research,
if weight is lost and/or partially regained. Because 7, 379–386.
many people are unsuccessful in maintaining initial Cash, T. F. (1994). Body image and weight changes in
a multisite, comprehensive very-low-calorie diet program.
weight loss, learning to increase body acceptance, Behavior Therapy, 25, 239–254.
as well as learning to manage the stigma associated Cash, T. F. (2002). The Situational Inventory of Body-Image
with weight, could potentially enhance quality of life. Dysphoria: Psychometric evidence and development of a short
Finally, as Schwartz and Brownell (2004) assert “One form. International Journal of Eating Disorders, 32, 362–
potentially dangerous conclusion that could be drawn 366.
Cash, T. F. (2004). Body-Image assessments: Manuals and
from the idea that even some body image distress is
questionnaires. Available from the author at http://www.body-
beneficial is that societal discrimination and stigma images.com.
are justified because they may help motivate people Cash, T. F., & Deagle III, E. A. (1997). The nature and extent
to change.” (p. 53) of body-image disturbances in anorexia nervosa and bulimia
nervosa: A meta-analysis. International Journal of Eating
Disorders, 22, 107–125.
Cash, T. F., & Fleming, E. C. (2002a). Body image and
References social relations. In T. F. Cash & T. Pruzinsky (Eds.), Body
image: A handbook of theory, research, and clinical practice
Adami, G. F., Gandolfo, P., Campostano, A., Meneghelli, A., (pp. 277–286). New York: Guilford Press.
Ravera, G., & Scopinaro, N. (1998). Body image and body Cash, T. F., & Fleming, E. C. (2002b). The Impact of Body-Image
weight in obese patients. International Journal of Eating Experiences: Development of the body image quality of life
Disorders, 24, 299–306. inventory. International Journal of Eating Disorders, 31, 455–
Adami, G. F., Meneghelli, A., Bressani, A., & Scopinaro. (1999). 460.
Body image in obese patients before and after stable weight Cash, T. F., & Hrabosky, J. I. (2004). The treatment of body-image
reduction following bariatric surgery. Journal of Psychosomatic disturbances. In J. K. Thompson (Ed.), Handbook of eating
Research, 46, 275–281. disorders and obesity (pp. 515–541). New York: Wiley.
166 N.M. Annis et al. / Body Image 1 (2004) 155–167

Cash, T. F., & Labarge, A. S. (1996). Development of the Friedman, M. A., & Brownell, K. D. (1995). Psychological
Appearance Schemas Inventory: A new cognitive body-image correlates of obesity: Moving to the next research generation.
assessment. Cognitive Therapy and Research, 20, 37–50. Psychological Bulletin, 117, 3–20.
Cash, T. F., & Roy, R. E. (1999). Pounds of flesh: Weight, Friedman, M. A., & Brownell, K. D. (2002). Psychological
gender, and body images. In J. Sobal & D. Maurer (Eds.), consequences of obesity. In C. G. Fairburn & K. D. Brownell
Interpreting weight: The social management of fatness and (Eds.), Eating disorders and obesity: A comprehensive
thinness (pp. 209–228). Hawthorne, NY: Aldine de Gruyter. handbook (2nd ed., pp. 393–398). New York: Guilford Press.
Cash, T. F., & Strachan, M. D. (2002). Cognitive-behavioral Gormally, J., Black, S., Daston, S., & Randin, D. (1982). The
approaches to changing body image. In T. F. Cash & T. assessment of binge eating severity among obese persons.
Pruzinsky (Eds.), Body image: A handbook of theory, research, Addictive Behaviors, 7, 47–55.
and clinical practice (pp. 478–486). New York: Guilford Press. Gortmaker, S. L., Must, A., Perrin, J. M., Sobol, A. M., & Deitz, W.
Cash, T. F., Counts, B., & Huffine, C. E. (1990). Current H. (1993). Social and economic consequences of overweight in
and vestigial effects of overweight among women: Fear of adolescence in adolescence and young adulthood. New England
fat, attitudinal body image, and eating behaviors. Journal Journal of Medicine, 329, 1008–1012.
of Psychopathology and Behavioral Assessment, 12, 157– Grilo, C. M. (2002). Binge eating disorder. In C. G. Fairburn
167. & K. D. Brownell (Eds.), Eating disorders and obesity: A
Cash, T. F., Beskin, C. L., & Yamamiya, Y. (July, 2001). Body comprehensive handbook (2nd ed., pp. 178–182). New York:
image, sexual self-schemas, and sexual functioning among Guilford Press.
college women and men. Poster presented at the World Harvey, E. L., & Hill, A. J. (2001). Health professionals’ views
Congress of Behavioral and Cognitive Therapies, Vancouver, of overweight people and smokers. International Journal of
Canada. Obesity, 25, 1253–1261.
Cash, T. F., Jakatdar, T. A., Williams, E. F. (in press). The Body Hebl, M. R., & Xu, J. (2001). Weighing the care: Physicians’
Image Quality of Life Inventory: Further validation with college reactions to the size of a patient. International Journal of
men and women. Body Image: An International Journal of Obesity, 25, 1246–1252.
Research. Heinberg, L. J., Thompson, J. K., & Matzon, J. L. (2002).
Chandarana, P. C., Conlon, P., Holliday, R. L., & Deslippe, Body image dissatisfaction as a motivation for health lifestyle
T. (1990). A prospective study of psychosocial aspects of change: Is some distress beneficial? In R. H. Striegel-Moore
gastric stapling surgery. Psychiatric Journal of the University & L. Smolak (Eds.), Eating disorders: Innovative directions
of Ottawa, 15, 32–35. in research and practice (pp. 215–232). Washington, DC:
Cooper, Z., & Fairburn, C. G. (2002). Cognitive-behavioral American Psychological Association.
treatment of obesity. In T. A. Wadden & A. J. Stunkard (Eds.), Helmreich, R., & Stapp, J. (1974). Short form of the Texas
Handbook of obesity treatment (pp. 465–479). New York: Social Behavior Inventory (TSBI): An objective measure of
Guilford Press. self-esteem. Bulletin of Psychonomic Society, 4, 473–475.
Cramer, P., & Steinwart, T. (1998). Thin is good, fat is bad: Isacsson, A., Frederiksen, S. G., Nilsson, P., & Hedenbro, J. L.
How early does it begin? Journal of Applied Developmental (1997). Quality of life after gastroplasty is normal: A controlled
Psychology, 19, 429–451. study. European Journal of Surgery, 163, 181–186.
Flegal, K. M., Carroll, M. D., Ogden, C. L., & Johnson, C. L. Jackson, L. A. (2002). Physical attractiveness: A sociocultural
(2002). Prevalence and trends in obesity among US adults, perspective. In T. F. Cash & T. Pruzinsky (Eds.), Body image:
1999–2000. Journal of the American Medical Association, 288, A handbook of theory, research, and clinical practice
1723–1727. (pp. 13–21). New York: Guilford Press.
Foster, G. D., & Matz, P. E. (2002). Weight loss and changes Lean, M. E., Han, T. S., & Seidell, J. C. (1999). Impairment of
in body image. In T. F. Cash & T. Pruzinsky (Eds.), Body health and quality of life using new U.S. federal guidelines
image: A handbook of theory, research, and clinical practice for the identification of obesity. Archives of Internal Medicine,
(pp. 405–413). New York: Guilford Press. 159, 837–843.
Foster, K. Y., Diehl, N. S., Shaw, D., Rogers, R. L., Egan, B., Leary, M. R. (1983). A brief version of the Fear of Negative
Carek, P., & Tomsic, J. (2002). Medical students’ readiness Evaluation scale. Personality and Social Psychology Bulletin,
to provide lifestyle counseling for overweight patients. Eating 9, 371–375.
Behaviors, 3, 1–13. Lewis, R. J., Cash, T. F., Jacobi, L., & Bubb-Lewis, C. (1997).
Foster, G. D., Wadden, T. A., & Vogt, R. A. (1997). Body image in Prejudice toward fat people: The development and validation
obese women before, during, and after weight loss treatment. of the Anti-fat attitudes test. Obesity Research, 5, 297–
Health Psychology, 16, 226–229. 307.
French, S. A., Jeffery, R. W., Sherwood, N. E., & Miller, C. T., Rothblum, E. D., Brand, P. A., & Felicio, D. M.
Neumark-Sztainer, D. (1999). Prevalence and correlates of (1995). Do obese women have poorer social relationships than
binge eating in a nonclinical sample of women enrolled nonobese women? Reports by self, friends, and coworkers.
in a weight gain prevention program. International Journal Journal of Personality, 63, 65–85.
of Obesity and Related Metabolic Disorders, 23, 576– Mussell, M. P., Mitchell, J. E., de Zwaan, M., Crosby,
585. R. D., Seim, H. C., & Crow, S. J. (1996). Clinical
 N.M. Annis et al. / Body Image 1 (2004) 155–167 167

characteristics associated with binge eating in obese families: severity, and clinical significance. Journal of Consulting and
A descriptive study. International Journal of Obesity, 20, 324– Clinical Psychology, 66, 651–654.
331. Schwartz, M. B., & Brownell, K. D. (2002). Obesity and
Myers, A., & Rosen, J. C. (1999). Obesity stigmatization and body image. In T. F. Cash & T. Pruzinsky (Eds.), Body
coping: Relation to mental health symptoms, body image, and image: A handbook of theory, research, and clinical practice
self-esteem. International Journal of Obesity, 23, 221–230. (pp. 200–209). New York: Guilford Press.
Neumark-Sztainer, D., & Haines, J. (2004). Psychosocial and Schwartz, M. B., & Brownell, K. D. (2004). Obesity and body
behavioral consequences of obesity. In J. K. Thompson (Ed.), image. Body Image: An International Journal of Research, 1,
Handbook of eating disorders and obesity (pp. 349–371). New 43–56.
York: Wiley. Smith, D. E., Marcus, M. D., Lewis, C. E., Fitzgibbon, M.,
Noles, S. W., Cash, T. F., & Winstead, B. A. (1985). Body image, & Schreiner, P. (1998). Prevalence of binge eating disorder,
physical attractiveness, and depression. Journal of Consulting obesity, and depression in a biracial cohort of young adults.
and Clinical Psychology, 53, 88–94. Annals of Behavioral Medicine, 20, 227–232.
Ogden, C. L., Flegal, K. M., Carroll, M. D., & Johnson, C. L. Stake, J. E., & Laurer, M. L. (1987). The consequences of being
(2002). Prevalence and trends in overweight among US children overweight: A controlled study of gender differences. Sex
and adolescents, 1999–2000. Journal of the American Medical Roles, 17, 31–47.
Association, 288, 1728–1732. Stice, E. (2002). Body image and bulimia nervosa. In T. F. Cash
Pingitore, R., Dugoni, B. L., Tindale, R. S., & Spring, B. & T. Pruzinsky (Eds.), Body image: A handbook of theory,
(1994). Bias against overweight job applicants in a simulated research, and clinical practice (pp. 304–311). New York:
employment interview. Journal of Applied Psychology, 79, Guilford Press.
909–917. Tabachnick, B. G., & Fidell, L. S. (2001). Computer-assisted
Pi-Sunyer, F. X. (2002). Medical complications of obesity in research design and analysis. Boston: Allyn and Bacon.
adults. In C. G. Fairburn & K. D. Brownell (Eds.), Eating Telch, C. F., Agras, W. S., & Rossiter, E. M. (1988). Binge eating
disorders and obesity: A comprehensive handbook (2nd ed., increases with increasing adiposity. International Journal of
pp. 467–472). New York: Guilford Press. Eating Disorders, 7, 115–119.
Powell, M. R., & Hendricks, B. (1999). Body schema, gender, Tiggemann, M. (2002). Media influences on body image
and other correlates in nonclinical populations. Genetic, Social, development. In T. F. Cash & T. Pruzinsky (Eds.), Body
and General Psychology Monographs, 125(4), 333–412. image: A handbook of theory, research, and clinical practice
Price, J. H., Desmond, S. M., Krol, R. A., Snyder, F. F., & (pp. 91–98). New York: Guilford Press.
O’Connell, J. K. (1987). Family practice physicians’ beliefs Tiggemann, M., & Rothblum, E. D. (1988). Gender differences
attitudes, and practices regarding obesity. American Journal of in social consequences of perceived overweight in the United
Preventive Medicine, 3, 339–345. States and Australia. Sex Roles, 18, 75–86.
Puhl, R., & Brownell, K. D. (2001). Bias, discrimination, and Wadden, T. A., Brownell, K. D., & Foster, G. D. (2002). Obesity:
obesity. Obesity Research, 9, 788–805. Responding to the global epidemic. Journal of Consulting and
Puhl, R., & Brownell, K. D. (2002). Stigma, discrimination, and Clinical Psychology, 70, 510–525.
obesity. In C. G. Fairburn & K. D. Brownell (Eds.), Eating Wadden, T. A., Womble, L. G., Stunkard, A. J., & Anderson, D.
disorders and obesity: A comprehensive handbook (2nd ed., A. (2002). Psychosocial consequences of obesity and weight
pp. 108–112). New York: Guilford Press. loss. In T. A. Wadden & A. J. Stunkard (Eds.), Handbook of
Radloff, L. S. (1977). The CES-D scale: A self-report depression obesity treatment (pp. 144–169). New York: Guilford Press.
scale for research in the general population. Applied Webber, E. (1994). Psychological characteristics of bingeing and
Psychological Measurement, 1, 385–401. nonbingeing obese women. Journal of Psychology, 128, 339–
351.
Roehling, M. V. (1999). Weight-based discrimination in
Wiederman, M. W. (2002). Body image and sexual functioning.
employment: Psychological and legal aspects. Personnel
In T. F. Cash & T. Pruzinsky (Eds.), Body image: A handbook
Psychology, 52, 969–1016.
of theory, research, and clinical practice (pp. 287–294). New
Rosen, J. C. (2002). Obesity and body image. In C. G. Fairburn
York: Guilford Press.
& K. D. Brownell (Eds.), Eating disorders and obesity: A
Wilfley, D. E., Wilson, G. T., & Agras, W. S. (2003). The clinical
comprehensive handbook (2nd ed., pp. 399–402). New York:
significance of binge eating disorder. International Journal of
Guilford Press.
Eating Disorders, 34, S96–S106.
Rosen, J. C., Orosan, P., & Reiter, J. (1995). Cognitive behavior
Womble, L. G., Williamson, D. A., Martin, C. K., Zucker, N. L.,
therapy for negative body image in obese women. Behavior
Thaw, J. M., Netemeyer, R., Lovejoy, J. C., & Greenway, F.
Therapy, 26, 25–42.
L. (2001). Psychosocial variables associated with binge eating
Sarwer, D. B., & Thompson, J. K. (2002). Obesity and body
in obese males and females. International Journal of Eating
image disturbance. In T. A. Wadden & A. J. Stunkard (Eds.),
Disorders, 30, 217–221.
Handbook of obesity treatment (pp. 447–464). New York:
World Health Organization. (1998). Obesity: Preventing
Guilford Press.
and managing the global epidemic. (Publication No.
Sarwer, D. B., Wadden, T. A., & Foster, G. D. (1998). Assessment
WHO/NUT/NCD 98.1). Geneva: World Health Organization.
of body image dissatisfaction in obese women: Specificity,