Abstract
“Obese women are deprived of jobs and income despite good education, they seem at higher risk of being socially isolated both regarding intimate relationships and friendships, and they may suffer from lower self-esteem and more depression than obese men”
Obesity is rapidly increasing throughout the world. In less than 50 years its prevalence has increased in many countries, and today overweight and obese people are more the norm than a curiosity. Globally, there are more than 1 billion overweight adults, and around a third of them are obese [1]. With its severe effects on health and disease, obesity is one of the world's most threatening health hazards, Type 2 diabetes, cardiovascular disease, hypertension, stroke and certain cancers being its most apparent consequences [1]. In addition, societal pressures against obesity are strong and many studies document that being overweight is considered self-inflicted and a sign of weakness and lack of character. In accordance, several reports suggest that quality of life is grossly reduced among obese people. For instance, one study reported that mental wellbeing was worse among the obese than among the chronically ill or injured [2]. Another study found that obese people are more likely to report serious emotional problems [3]. Obesity also has severe consequences for other aspects of psychosocial wellbeing in general, which may to some constitute more of an immediate burden than the physical health consequences. The obese are being stigmatized by peers, relatives, health personnel, educators and employers. Studies show, for instance, that peers view the obese as different and undesirable, which results in teasing, bullying and social exclusion [4–7]. Also, family members have been observed to tease and critisize [5,8,9]. Paradoxically, health personnel may also take complaints from obese patients less seriously than complaints from normal-weight patients. One study documented that doctors spend less time dealing with their obese patients' problems [10], and another that obese women were less likely to be screened for cervical and breast cancer than normal-weight women [11]. Despite evidence that obesity is not a simple consequence of too much food and too little exercise, but rather develops as a complicated interplay between genes, environmental factors such as food intake and exercise, social, cultural and psychological factors, the general attitude still seems to be that the obese are responsible for their own state of fatness, and simply need to pull themselves together: eat less and exercise more. Arguably, this attitude does not hold relevance for small children, but many studies document that even very young obese children are stigmatized. They suffer more teasing, more physical bullying, and are more often excluded from friendships and interplay with peers. For instance, one often-quoted study among 3–5-year-old children found that the overweight children ranked lowest in the social hierarchy and were excluded from peer interaction. The other children preferred the children with scars or various physical handicaps to the overweight children [12]. Other studies show that overweight children are more often called names, threatened or made fun of than normal-weight children [5,6,8,13], and that this social bullying also includes isolation, or having rumors and lies spread about them [4,6,7]. In addition, studies suggest that adults also hold negative attitudes towards obese children that are expressed in very subtle and potentially sometimes unconscious ways. Indeed, in one study, 20 mothers of normal-weight boys were asked to tell fictive stories from three photographs. One was a photo of a normal-weight boy, another photo of a handicapped boy and the third a photo of an obese boy. Interestingly, four out of five stories about the handicapped boy were about having success as were approximately half of the stories told about the normal-weight boy. However, not one of the fictive stories about the obese boy was about success [14]. The authors concluded that parents do transmit their negative view of obesity to their children and that this, in part, might account for using the pervasive physical attractiveness stereotype [14]. Also, schoolteachers have been found to hold negative attitudes against their overweight students, who they characterize as untidy, more emotional, with family problems and less likely to succeed at work [15].
Regrettably, a number of studies also suggest that girls and women may tend to suffer more from their obesity than do boys and men. Not only do women generally have a higher occurrence of obesity than men [1], they also seem at a greater health disadvantage because of a higher risk of comorbid conditions, especially Type 2 diabetes and heart disease [16–18]. Indeed, the risk of developing Type 2 diabetes as an obese woman may be more than double that for obese men [17,18]. However, it may generally be less recognized that women also seem to experience more psychosocial consequences related to obesity than men. Indeed, studies show a stronger association between stigmatization and lower psychological well-being among overweight women than among overweight men [19–21]. Obese women are deprived of jobs and income despite good education [22–27], they seem at higher risk of being socially isolated both regarding intimate relationships [6,28,29] and friendships [7], and they may suffer from lower self-esteem and more depression than obese men [3,21,30–32]. Studies even find that overweight girls and women have a higher rate of suicidal thoughts compared with overweight boys and men [3,21,30–32]. Overweight girls also seem to experience more stigmatization in relation to education than overweight boys. In this regard, studies show that overweight college girls may receive less financial parental support than overweight college boys, and also that the overweight girls, but not overweight boys, are under-represented at prestigious universities [33,34]. In line with this, a much-cited study by Gortmaker and colleagues reported that obese women in the USA had completed fewer years of schooling, had a lower income and a higher frequency of poverty [35]. However, even with equal education, overweight women are stigmatized. Indeed, Finnish data have shown that overweight, well-educated women seem to have a harder time getting established in the labor market than overweight men or normal-weight women, and may end up with lower incomes and poorer jobs than normal-weight women of similar high education, whereas, among men, job opportunities and income seem related to education only [26,27].
“Spreading the word that overweight occurs as a consequence of a complicated interaction between our genes and our lifestyle, and is influenced by social, psychosocial and cultural factors, rather than just a simple consequence of too much food and too little exercise, may help to prevent further stigmatization of the obese, irrespective of gender.”
It is presumed that women may be more influenced by stigmatization due to a greater internalization of their stigmatization [20], because women may base their self-esteem on looks more than men do [36]. Above all, they, and others, may see the female body as a means of attraction, whereas men may regard their bodies as a mean of performing effectively in external environments [36]. In accordance, it has been shown that, compared with overweight young men, overweight young women are considered less worthy of dating [6,28], and are more often unmarried [35].
In stigmatization research it is debated whether stigmatization of the obese and overweight contributes to a higher prevalence of obesity by itself. Stigmatization is associated with a negative body image, body dissatisfaction and low self-esteem, which may cause increased overeating and an inactive lifestyle [37]. For instance, Storch and colleagues found that one reason for an inactive lifestyle in obese individuals was bullying [38], and Eisenberg and colleagues reported that bullying was related to developing eating disorders [39]. By contrast, a high self-esteem seems to be related to prevention of weight gain among adolescents [40]. The importance of focusing on a reduction in stigmatization of obese individuals must be seen in relation to the recent obesity epidemic, particularly since the recent rise in obesity does not seem to be followed by a reduction in the stigmatization, which may otherwise be expected to occur, when overweight becomes more of a norm. Rather, recent data suggest that stigmatization of the obese has increased from 1961–2001 [12]. Spreading the word that overweight occurs as a consequence of a complicated interaction between our genes and our lifestyle, and is influenced by social, psychosocial and cultural factors, rather than just a simple consequence of too much food and too little exercise, may help to prevent further stigmatization of the obese, irrespective of gender.