A number of reviews have been published on the psychosocial aspects of obesity (124-128, 183). The specific topics that will be reviewed here include:
In American and other Westernized societies there are powerful messages that people, especially women, should be thin, and that to be fat is a sign of poor self-control (125, 126, 128, 184, 185). Negative attitudes about the obese have been reported in children and adults (186-191), in health care professionals (192-194), and in the overweight themselves (195, 196).
People's negative attitudes toward the obese often translate into discrimination in employment opportunities (197-199), college acceptance (200), less financial aid from their parents in paying for college (195, 201), job earnings (202), rental availabilities (203), and opportunities for marriage (204).
Much of the research on the social stigma of obesity has suffered from methodological limitations. For example, a number of the early studies relied on line drawings rather than more lifelike representations of obese people and on checklists that forced one to make YES or NO choices. More important, there has been a lack of research that has looked at the impact of obesity in the context of other variables, such as physical attractiveness, the situational context, and the degree of obesity (184, 185). In addition, social stigma toward the obese has primarily been assessed among white individuals.
There is some evidence that members of other racial and ethnic groups are less harsh in their evaluation of obese persons. One study assessed 213 Puerto Rican immigrants to the United States, and found a wide range of acceptable weights among them (205). Crandall found that Mexican students were significantly less concerned about their own weight and were more accepting of other obese people than were U.S. students (206).
In addition, the degree of acceptance of obesity among people of lower education and income has not been well studied. Thus, these data are very incomplete with respect to racial and ethnic groups other than whites.
Research relating obesity to psychological disorders and emotional distress is based on community studies and clinical studies of patients seeking treatment. In general, community-based studies in the United States have not found significant differences in psychological status between the obese and nonobese (126, 183, 207, 208). However, several recent European studies in general populations do suggest a relationship between obesity and emotional problems (209-211).Thus, it may be premature to state that there is no association between obesity and psychopathology or emotional distress in the general population. More focused, hypothesis-driven, and long-term studies are needed (127, 212).
Overweight people seeking weight loss treatment may, in clinic settings, show emotional disturbances (213-215). In a review of dieting and depression, there was a high incidence of emotional illness symptoms in outpatients treated for obesity (213). However, several factors influenced these emotional responses, including childhood onset versus adult onset of obesity (those with childhood onset obesity appear more vulnerable). Another study that compared different eating disorder groups found that obese patients seeking treatment showed considerable psychopathology, most prominently mild to severe depression (214). Sixty-two percent of the obese group seeking treatment showed clinically significant elevations on the depression subscale of the Minnesota Multiphasic Personality Inventory, and 37 percent of this same group showed a score of 20 or higher (indicating clinical depression) on the Beck Depression Inventory. Focusing on depression was considered an important component of the weight loss program.
Another study compared obese people who had not sought treatment to an obese group that had sought treatment in a professional, hospital-based program, and to normal weight controls (215). Again, obese individuals seeking treatment reported more psychopathology and binge eating compared to the other groups. Both obese groups reported more symptoms of distress than did normal weight controls. The authors suggest that the obese population is not a homogenous group, and thus, may not respond in the same way to standardized treatment programs. In particular, obese individuals seeking treatment in clinic settings are more likely than obese individuals not seeking treatment and normal controls to report more psychopathology and binge eating.
Binge eating disorder (BED) is characterized by eating larger amounts of food than most people would eat in a discrete time period (e.g., 2 hours) with a sense of lack of control during these episodes (762). It is estimated to occur in 20 to 50 percent of individuals who seek specialized obesity treatment (216-218). In community-based samples, the prevalence is estimated to be approximately 2 percent (219).
Comparisons have been made between BED and bulimia nervosa (BN), an eating disorder characterized by recurrent and persistent binge eating, accompanied by the regular use of behaviors such as vomiting, fasting, or using laxatives. Studies comparing normal-weight individuals who have BN with obese BED individuals have found that obese binge eaters are less likely to demonstrate dietary restraint and show few if any adverse reactions to moderate or severe dieting. Most obese binge eaters do not engage in inappropriate compensatory behaviors such as purging (220).
Compared with BN, the demographic distribution of BED is broader with respect to age, gender, and race (218, 219, 221-225), while data suggest that BED is as common in African-American women as in white women (226).The difference between BED and BN is dramatic regarding gender. Very few men have BN (227), whereas the distribution is close to equal in BED (225, 228, 229).
Compared to obese nonbingers, obese individuals with BED tend to be heavier (230), report greater psychological distress, and are more likely to have experienced a psychiatric illness (especially affective disorders) (225, 231-236). They also report an earlier onset of obesity and a greater percentage of their lifetime on a diet (237, 238).
Some studies have shown histories of greater weight fluctuation or weight cycling in obese binge eaters compared with nonbingers (219, 237, 238), but others have not (239). These individuals are also more likely than nonbinging obese people to drop out of behavioral weight loss programs (233), and to regain weight more quickly (220, 233, 240).
Critics of behavioral treatment of obesity have argued that caloric restriction may cause or contribute to the episodes of binge eating and BN (241). Three studies have tested this hypothesis (218, 242, 243). Neither moderate nor severe caloric restriction exacerbated binge eating. All three studies showed that weight control treatment featuring caloric restriction significantly reduced the frequency of binge eating in these patients.
Body image is defined as the perception of one's own body size and appearance and the emotional response to this perception (183, 244). Inaccurate perception of body size or proportion and negative emotional reactions to size perceptions contribute to poor body image. Obese individuals, especially women, tend to overestimate their body size (245-249).
People at greater risk for a poor body image are binge eaters, women, those who were obese during adolescence or with early onset of obesity, and those with emotional disturbances (127, 235, 244, 250-253). It is no surprise, then, that in some groups of obese persons, these individuals are more dissatisfied and preoccupied with their physical appearance, and avoid more social situations due to their appearance (254, 255).
Body image dissatisfaction and the desire to improve physical appearance often drives individuals to seek weight loss. However, obese persons seeking weight reduction must come to terms with real limits in their biological and behavioral capacities to lose weight. Otherwise, weight loss attempts may only intensify the sense of failure and struggle that is already present among many obese individuals. For this reason, psychosocial interventions which incorporate strategies to improve body image may be helpful for those who want to lose weight and are very concerned about their physical appearance. A review of body image interventions in obese persons can be found in Rosen (256).
Body image perceptions of individuals in various ethnic and racial groups may be different, on average, from those of the mainstream culture. There may be a similar range of attitudes but on a different scale; for example, it may take a much greater degree of overweight to elicit negative reactions (257). Differences in body image and weight-related concerns between black and white girls and women have been observed (257). In general, black girls and women report less social pressure to be slim (258-260), fewer incidences of weight-related discrimination (261), less weight and body dissatisfaction, and greater acceptance of overweight than their white counterparts (259, 262-266).
College-age black women report less concern and fear about fatness, less drive to be thin, and less concern about dieting than do college-age white women (267). In addition, black women may ascribe some positive qualities to being large, such as having stamina, strength, and solidity, and are less likely to link body size to health than white women. Black elementary school and high school girls were more likely to be trying to gain weight (268, 269) and less likely to be trying to lose weight as compared to white girls (269).
Because of the above, it is possible that weight control initiatives may elicit different reactions from black and white women. Less is known about the relationship between obesity and body image disturbance in other racial and ethnic groups (270).