Review Obesity

EPIDEMIOLOGY/GENETICS

Weight Stigma “Gets Under the Skin”—Evidence for an Adapted

Psychological Mediation Framework—A Systematic Review
Claudia Sikorski1,2,3, Melanie Luppa1, Tobias Luck1,4, and Steffi G. Riedel-Heller1

Objective: Research consistently shows a negative view of individuals with obesity in the general public
and in various other settings. Stigma and discrimination can be considered chronic stressors, as these
factors have a profound impact on the psychological well-being of the affected individuals. This article
proposes a framework that entails a mediation of the adverse effects of discrimination and stigmatization
on mental well-being through elevated psychological risk factors that are not unique to weight but that
could affect overweight and normal-weight individuals alike.
Methods: A systematic review was conducted to assess the prevalence of psychological risk factors,
such as self-esteem and coping, in individuals with obesity.
Results: Forty-six articles were assessed and included for detailed analysis. The number of studies on
these topics is limited to certain dimensions of psychological processes. The best evaluated association
of obesity and psychosocial aspects is seen for self-esteem. Most studies establish a negative associa-
tion of weight and self-esteem in children and adults. All studies with mediation analysis find a positive
mediation through psychological risk factors on mental health outcomes.
Conclusions: This review shows that elevated psychological risk factors are existent in individuals with
obesity and that they may be a mediator between weight discrimination and pathopsychological outcomes.
Obesity (2015) 23, 266–276. doi:10.1002/oby.20952

Introduction
In light of limited intervention success for reducing obesity (1), psy-
chological and psychosocial aspects have come to the attention of obe-
sity intervention efforts. Some researchers now propose to consider
obesity even a “neuropsychological disease” (2). One underlying factor
of this assumption is the consideration of stress and chronic stressors
as an antecedent of obesity. A chronic stress-based activation of the
HPA-axis leads to elevated food intake, especially for energy-dense
foods (3). Chronic stress has also been linked to depression (4) and
depression to obesity (5). Chronic stress may therefore play a central
role not only in the development but also in the persistence of obesity.
Stigma as a stressor
While the prevalence of obesity has risen during the last years, so
has the prevalence of reported obesity discrimination (6). Also,
research consistently shows a negative view of individuals with obe-
sity in the general public (7) and in various other settings (8).
Research in obesity stigma has gained momentum during the past
years but still lacks theoretical and empirical evidence in several
ways. Its societal origin has been studied, revealing certain attitudes
(e.g., just world beliefs) and causal beliefs (e.g., attributing obesity
to individual failure) as major drivers of public stigma (9). The con-
sequences for the affected individuals and the theoretical back-
ground of these consequences, however, still leave many questions
unanswered. A vicious cycle model has been proposed lately:
Tomiyama (2014) hypothesizes that weight stigma leads to further
weight gain and difficulty of weight loss due to increased eating
behavior and cortisol stress response (10). Stigma and discrimination
are then considered chronic stressors which have a profound impact
on the psychological and physical well-being of the affected individ-
uals. A variety of studies links weight stigma to direct behavioral
change, such as an increase in eating behavior, psychosocial stress
observed on the HPA-axis), and indirect effect through social rela-
tionships (for an overview: Brewis, 2014 (11)). A theoretical model,
undermining and explaining the mechanisms of these associations is
still lacking.

1
Institute of Social Medicine, Occupational Health and Public Health (ISAP), University of Leipzig, Germany. Correspondence: Claudia Sikorski
(claudia.sikorski@medizin.uni-leipzig.de) 2 Leipzig University Medical Center, IFB Adiposity Diseases, Leipzig, Germany 3 Mailman School of Public
Health, Department of Epidemiology, Columbia University, New York City, New York, USA 4 LIFE—Leipzig Research Center for Civilization Diseases,
University of Leipzig, Leipzig, Germany.

Funding agencies: This work was supported by a fellowship within the Postdoc-Program of the German Academic Exchange Service (DAAD) and by the Federal Ministry
of Education and Research (BMBF), Germany, FKZ: 01EO1001.
Disclosure: The authors declared no conflict of interest.
Author contributions: All authors contributed to the development of the research question. CS conducted the systematic literature review, and ML and TL supported in
screening all abstracts. CS wrote a draft manuscript which all authors read and revised. All authors were involved in writing the paper and had final approval of the
submitted and published versions.
Received: 4 July 2014; Accepted: 30 September 2014; Published online 31 December 2014. doi:10.1002/oby.20952

266 Obesity | VOLUME 23 | NUMBER 2 | FEBRUARY 2015 www.obesityjournal.org

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EPIDEMIOLOGY/GENETICS
Figure 1 Psychological mediation framework (16).
From the minority stress paradigm to a
mediation framework in weight stigma
Research from other areas, such as sexual minority stigma, relies on
assumptions of the minority stress paradigm (12). This paradigm gives
theoretical explanations for the increased prevalence of mental health
disorders in sexual minorities, a premise that has been described in
obesity as well. Depression (5) and anxiety disorders (13) are more
prevalent in individuals with obesity. This outcome may be associated
with the minority status in a society. Being a member of stigmatized
group, such as a sexual minority or people with obesity, is associated
with efforts of trying to “fit in” (14) and the constant confrontation
with devaluation (15) which can create chronic stress. The minority
stress paradigm then describes two kinds of stressors: distal and proxi-
mal stressors. They refer to the psychological proximity to the affected
individual. Stigmatization and discrimination are called distal stressors
that lead to proximal stressors. Such proximal stressors include rejec-
tion sensitivity, concealment, and internalized stigma (12), which may
subsequently be associated with impaired mental health outcomes.
They reflect the subjective appraisal component of general stress
theory (12). Proximal stressors are closely related to an increased risk
of impaired mental health outcomes (16).
Taking these assumptions into account, a psychological mediation frame-
work has been proposed for sexual minority stigma, integrating the minor-
ity stress paradigm and general psychological risk factors to one model
(16). Hatzenbuehler thereby integrates two lines of research in sexual
minority stigma research: Group-specific processes which evolve from the
confrontation of being a minority and associated proximal stressors, such
as internalized stigma, are components of the minority stress paradigm
which are matched with general psychological factors that have been asso-
ciated with clinical outcomes in heterosexual samples.
The framework entails a mediation of the adverse effects of discrim-
ination and stigmatization on mental health through group-specific
proximal stressors as well as general psychological risk factors, that
are not unique to weight, but that could affect overweight and
normal-weight people alike. General psychological risk factors
include cognitive, emotional, and social processes. Hatzenbuehler
specifically differentiates general psychological risk factors from
group-specific proximal stressors that may even interact with each
other in the pathogenesis of mental health disorders (see Figure 1).
General psychological risk factors are split in three domains: Emo-
tional, social, and cognitive. Emotional factors entail concepts of
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Obesity
rumination, emotional dysregulation, and coping. The concept of cop-
ing is of special importance in the context of obesity as it can be
viewed as an attempt to reduce discomfort and distress during stress-
ful events—hence an adaptive process during perceived stigmatization
and discrimination (17). Social and inter-personal risk factors include
social isolation and imposed social norms, while hopelessness and
negative self-schemas, including low self-esteem, are considered cog-
nitive factors. Group-specific processes, e.g., proximal stressors,
include aspects that are based on subjective appraisal following distal
stressors (discrimination experiences). In sexual minority stigma, con-
cealment and internalized stigma play an important role. Internalized
stigma describes the phenomenon that stigmatized individuals inter-
nalize negative attributes ascribed to them, regarding them as fitting.
The mediation model then posits that the elevated psychological risk
factors that are seen in minority groups are set off and activated by
stigmatization and discrimination (Figure 1). Group-specific proxi-
mal stressors further contribute to the increased risk for impaired
mental health outcomes. This kind of theoretical model is lacking in
obesity stigma research. This article therefore sets out to fill this
research gap by reviewing the current literature based on an estab-
lished theoretical model.
In the current study, we examine whether the psychological mediation
model can be adapted to individuals with obesity. Although obesity
stigma varies from other types of stigma, such as the sexual minority
stigma, simply because it is a non-concealable, visible condition, the
same mechanism may be at work in regard to psychological risk factors
and group-specific processes, such as internalized stigma. The strong
relationship between perceived discrimination and psychopathology
supports that assumption (18) and it may be particularly true for obesity
as visibility and perceived controllability are drivers in stigmatization
(19). Both can be seen as relevant in obesity stigma (20). In terms of a
broader theoretical framework, Major and O’Brien (2005) refer to the
identity threat paradigm that establishes perceived stigmatization as an
experience that threatens a person’s social identity (21). It has been
shown to be valid for individuals with obesity as well (22). It is linked
to involuntary (emotional and cognitive reactions that do not regulate
stressful events) and voluntary components (coping behaviors that may
alter the perception of the event). Both components are found in Hat-
zenbuehler’s model and can be expected to occur in a general stigmatiz-
ing environment as obesity as well. Understanding psychological risk
factors that are influenced by discrimination is of great importance
when considering including psychological aspects in interventions tar-
geted at individuals with obesity.
Based on the framework, we hypothesize that (a) obese individuals
experience chronic stress based on stigmatization and discrimination,
which leads to group-specific proximal stressors and elevated psy-
chological risk factors compared to normal-weight individuals that
in turn (b) mediate the relationship between stigma, discrimination,
and psychopathology. These hypotheses are pursued in this system-
atic review. It sets out to review evidence in the literature that sup-
port a psychological mediation framework.
Methods
Procedure and search terms
This review was prepared according to the systematic literature
review guidelines of the Centre for Reviews and Dissemination (23)
and follows PRISMA (Preferred Reporting Items for Systematic
Obesity | VOLUME 23 | NUMBER 2 | FEBRUARY 2015 267
Obesity
Figure 2 Literature search. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
reviews and Meta-Analyses) suggestions (24). A systematic litera-
ture search available on the electronic databases PubMed, Web of
Science, and Cochrane Library was conducted in August 2014. The
terms (obes* OR adiposity* OR overweight* OR over-weight*)
AND (discrimination OR stigma OR rumination OR coping OR
social isolation OR social norms OR social support OR hopelessness
OR emotion dysregulation OR self-esteem OR self-worth OR nega-
tive self OR alcohol expectancy OR rejection sensitivity OR (rejec-
tion AND expect*) served as search criteria. In addition, the bibliog-
raphies of the selected articles were searched. Search terms were
derived from the original article by (16). Mark Hatzenbuehler gave
his advice for the inclusion of search terms. Additionally, all tables
in the review were re-visited and terms were included. The authors
chose to exclude concealment from the search term list as this was
not expected to play a role in obesity. A pre-review, unsystematic
search on PubMed yielded only 12 results which were screened and
evaluated not fitting for the review.
Inclusion criteria
Abstracts were screened using the following selection criteria: (i)
quantitative studies in (ii) German or English language (iii) report-
268 Obesity | VOLUME 23 | NUMBER 2 | FEBRUARY 2015
A Framework for Internalized Weight Stigma Sikorski et al.
ing aspects of the psychological risk factors of obese individuals in
comparison to normal-weight counterparts. This distinction was
made to ensure comparability. Relying on studies that investigate
general psychological elevations in obese-only populations lacks a
reference group and only describes intra-group differences that are
not the focus of this review. Studies were excluded when (iv) the
sample consisted of only patients presented with various comorbid-
ities, such as diabetes or polycystic ovary syndrome. Only published
articles were included in the review.
Data extraction
Titles and abstracts were screened to identify studies of likely rele-
vance and full papers obtained. Primarily, methodological data on
sampling, study design, explored constructs, and definition of out-
come criteria were extracted from all selected studies. Secondly, the
selection criteria described in the above section were then reapplied
to ensure accurate study inclusion.
Literature search
The results of the systematic literature search are shown in Figure 2.
Initially, 10,350 articles were found in the search. From those, 190
potentially relevant articles were identified after the screening of the
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EPIDEMIOLOGY/GENETICS
abstracts. Cohen’s j was run to determine the magnitude of agree-
ment between the two abstract screening authors. There was substan-
tial agreement between both raters, j 5 0.767 (P < 0.001). All
abstracts with disagreement between the two reviewers where re-
visited and discussed until consensus was reached. If in doubt, articles
were included for a detailed review. Additional 12 articles were found
in reference lists of other articles. After retrieving all full articles, 154
articles were rejected as not fulfilling the selection criteria. Again,
articles in question were discussed and another member of the
research team served as an independent intermediary. Consensus
within the research team was reached regarding inclusion of all
articles. In total, 46 articles were assessed and included for detailed
analysis. Studies were grouped according to sample (children/adoles-
cents vs. adults) and psychosocial risk factors under investigation.
Results
The extracted 46 articles provide a very heterogeneous basis of liter-
ature. To take this circumstance into account, the following section
reports their results grouped by risk factor as well model-based com-
ponents (psychological risk factors vs. group-specific processes).
One major finding is the identification of body image as a group-
specific process in obesity. As body image was not a selected search
term in the a priori defined list of terms, the number of studies here
is limited to studies that included body image among other out-
comes. We will therefore report and discuss these studies separately.
Psychological risk factors
Table 1 summarizes all studies that report evidence from psycholog-
ical risk factors that compared individuals with obesity to those with
normal weight. In total, 25 studies were found, and 21 investigated
the association of obesity and self-esteem in children and adoles-
cents. Seven studies in adult samples were found, reporting results
for different risk factors. Sample sizes differ substantially and vary
between n 5 64 and n 5 22,831.
Self-esteem. Out of 21 studies, only four (19%) postulated no
association of weight and global self-esteem in younger children and
adolescents. The comparability of these studies, however, may be
limited as we observe significant ethnic and cultural differences
between the study samples. Bang et al. (26), for example, report
results from a South Korean sample. While children with obesity
did not differ from normal-weight children in regard to global self-
worth, the overall measure of self-perception was significantly lower
among these children. Self-perception in this study was a rather
global and broad assessment of the children’s scholastic and athletic
competence, social acceptance, physical appearance, and behavioral
conduct. Accordingly, another Asian sample provided by the authors
Lee et al. (36) also shows a null association between self-esteem
and body weight. What this study does show is an impaired emo-
tional and psychosocial health status in children with obesity in
terms of impaired mental health outcomes. Another example for eth-
nic and cultural differences that may influence the results regarding
self-esteem is the third study finding no difference: Powell-Young
et al. (41) report results from an African American sample of girls
where 85% were classified as living in low-income households. This
is a feature shared by the study by Wong et al. (49) which reports
results from a sample of minority, low-income children. All other
studies clearly show an association of obesity and self-esteem in
children under the age of 18. A final conclusion, however, can only
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Obesity
be drawn cautiously, since other low-income or Asian samples show
an association of obesity and self-esteem (37,42), but differ from the
mentioned studies regarding assessment instrument and assessment
of BMI. In adult populations, three studies clearly confirm lower
self-esteem among individuals with obesity (52-54).
Coping mechanisms. Coping was assessed in two studies in chil-
dren. Confrontation as one specific way of coping with stigma (64)
was investigated in the study by Janssen et al. (34). Here participants
were asked how often they initiated bullying toward their peers them-
selves. The prevalence of so called bullying-perpetrators increased
with BMI categories in this study in certain age groups. Across all
age groups, girls were more likely to act as perpetrators when they
were obese, while the same was true for 15- to 16-year-old boys.
These results only serve as indicators of a more aggressive style of
coping since this study also finds a much higher prevalence of being
the victim of bullying among children with obesity. Other authors,
such as Martyn-Nemeth et al., use a specific 6-item coping question-
naire and provide a general coping score indicating coping ability
(37). The authors do not find a difference in coping ability. The num-
ber of studies is too small to draw any meaningful conclusions from
the body of evidence in children. In adults, three studies report
impaired coping skills in individuals with obesity (55-57). H€orchner
et al. (2002) compare their findings in n 5 94 female patients with
obesity to those of a normal-weight reference group and find signifi-
cant differences on several sub-scales of the Utrecht Coping List (55).
The patients reported an active approach less often, but report a
higher frequency of avoidance, depressive responses. Patients with
obesity also indicate to a higher level of emotional coping and pallia-
tive responses. The authors summarize that these differences may
even be higher since their sample consisted of patients that had
already sought help for their problem. These results are in line with
Ryden et al. (57). After weight loss emotional coping scores
decreased in formerly patients with obesity, while problem-focused
coping increased. The authors also show an increase in maladaptive
coping if participants gained weight during follow-up periods. Miller
et al. (1995) experimentally assessed the tendency for compensation
in obese women who were told they were or were not visible to a fic-
tive telephone partner (56). When the women with obesity thought
they were seen by their telephone partner, they were rated more lika-
ble and socially skilled by their partner than when they believed they
were not seen by the telephone partner. Results here indicate that
obese women made an effort to appear more desirable in order to
compensate for their visible weight.
Social support. Results for social support among individuals
with obesity are mixed and far from generalizability. Four studies
find lower social support in children (39,48), adolescents (50), and
adults with obesity (58), while another one does not in adolescents
(37). Higher levels of loneliness were reported in one study (40).
All studies differ substantially in regard to study design (assessment
of BMI), sample size, age range, and proportion of individuals with
obesity. Hence, a direct comparison does not seem reasonable.
Group-specific processes
Body dissatisfaction emerged as a group-specific process during this
review and is therefore reported to ensure completeness. There obvi-
ously exists a much larger body of evidence regarding body dissatis-
faction (65), which will be discussed below; however, these studies
were found without the specific search term as described before.
Obesity | VOLUME 23 | NUMBER 2 | FEBRUARY 2015 269
TABLE 1 Support for elevated psychological risk factors in obese populations relative to those with normal weight

Citation Design Sample Determination of obesity Predictor Instrument Support?

Psychological risk factors
Children
Aldaqal et al., 2013 (25) Longitudinal n 5 32 obese adolescents, n 5 32 Measured BMI according to CDC, 95th Self-esteem RSE Yes, lower levels of self-esteem in the obese participants
normal-weight adolescents (13-17 years) percentile
Bang et al., 2012 (26) Cross-sectional n 5 52 overweight, 40 obese, and 363 Measured BMI according to 95th Global self-worth SPPC (sub-scale) No
normal-weight children (grades 5-6) percentile
Bjornelv et al., 2011 (27) Cross-sectional n 5 8,090 adolescents (13-18 years) Measured BMI  25 Self-esteem RSE Yes, lower levels of self-esteem in the obese participants
Braet et al., 1997 (28) Cross-sectional n 5 139 obese and n 5 150 non-obese children Measured 120% over ideal body weighta General self-worth PCSC Yes, lower levels of self-worth in the obese participants
(9-12 years)
Erermis et al., 2004 (29) Cross-sectional n 5 30 obese, 30 non-clinical obese, and 30 Help-seeking participants in pediatric Self-esteem RSE Yes, lower levels of self-worth in the obese participants
normal-weight adolescents (12-16 years) endocrinology outpatient clinic
Fan et al., 2010 (30) Cross-sectional n 5 3,544 adolescents (grades 7-11) Measured BMI according to WGOCc Self-esteem EDI-3 (sub-scale) Yes, lower levels of self-worth in the obese participants
Fox et al., 2009 (31) Cross-sectional n 5 376 adolescents (11-14 years) Self-reported BMI according to Cole Self-esteem SPPC Yes, lower levels of self-worth in the obese participants
(2000)b
Franklin et al., 2006 (32) Cross-sectional n 5 2,831 children (mean age 11.3 years) Measured BMI according to CDC, 95th Global self-worth SPPC Yes, lower levels of self-worth in the obese participants
percentile
Goldfield et al., 2010 (33) Cross-sectional n 5 1,490 adolescents (grades 7-12) Measured BMI according to 95th Self-esteem CDI Yes, higher levels of negative self-esteem in the obese
percentile participants
Janssen et al., 2004 (34) Cross-sectional n 5 5,746 adolescents (11-16 years) Self-reported BMI according to Cole Coping---Confrontation One item, no scale Yes, obese participants (15-16 years old) more likely to
(2000)b perpetrate bullying
Lanza et al., 2013 (35) Cross-sectional n 5 2,636 girls (grade 6) Self-reported BMI according to CDC, Self-worth SPPC Yes, lower levels of self-worth in the obese participants
95th percentile
Lee et al., 2012 (36) Cross-sectional n 5 311 children (11-13 years) Measured BMI according to WHO (2007)d Self-esteem LAWSEQ No
Martyn-Nemeth et al., Cross-sectional n 5 101 adolescents (14-18 years) Self-reported BMI according to CDC, Self-esteem, coping, RSE, 6-item coping, Yes, lower levels of self-worth in the obese participants
2012 (37) 85th percentile social support MOS-SSS No differences in coping and social support
McClure et al., 2010 (38) Cross-sectional n 5 6,522 adolescents (12-16 years) Self-reported BMI according to CDC Self-esteem SPPC Yes, lower levels of self-worth in the obese participants
Morales et al. (2013) (39) Cross-sectional n 5 1,158 children (8-11 years) Measured BMI according to Cole (2000)b Social support KIDSSCREEN-52 Yes, lower levels of social support in the obese
participants
Peltzer et al., 2011 (40) Cross-sectional n 5 5,613 adolescents (13-15 years) Self-reported BMI  30 Loneliness One item Yes, loneliness was associated with overweight/obesity
Powell-Young et al., Cross-sectional n 5 264 African American adolescents Measured BMI according to  85th Self-esteem SPPC No differences in this African American sample
2013 (41) (14-18 years) percentile
Shin et al., 2008 (42) Cross-sectional n 5 413 children (grades 5-6) Measured BMI according to  95th Self-esteem SPPC Yes, lower levels of self-worth in the obese participants
percentile
Strauss et al., 2000 (43) Longitudinal with n 5 1,520 children (9-10 years at baseline) Self-reported and measured BMI Self-esteem SPPC Yes, esp. pronounced in some groups (obese Hispanic
4-year follow-up according to 95th percentile and white females)
Wang et al., 2009 (44) Longitudinal n 5 22,831 children (0-11 years at baseline) Self-reported BMI according to Self-esteem 4-item scale Yes, lower levels of self-esteem in the obese participants
Cole (2000)b
Wang et al., 2008 (45) Cross-sectional n 5 4,945 children (grade 5) Measured BMI according to Cole (2007)b Self-esteem 11-item scale Yes, lower levels of self-esteem in the obese participants
Willows et al., 2013 (46) Cross-sectional n 5 202 Cree descent children (mean age 10.7) Measured BMI according to WHO (2007) Global self-concept PHCSCS-2 Yes, lower levels of self-concept in the obese participants
Witherspoon et al., Cross-sectional n 5 235 African American adolescents Measured BMI according to CDC, 95th Self-esteem RSE Yes, lower levels of self-concept in the obese participants
2013 (47) (11-16 years) percentile
Wyne et al. (2014) (48) Longitudinal n 5 255 children (7-12 years) Measured BMI according to WHO (2007) Social support KIDSCREEN-27 Yes, lower levels of social support in the participants
TABLE 1. (continued).

Citation Design Sample Determination of obesity Predictor Instrument Support?

Wong et al., 2014 (49) Cross-sectional n 5 910 low-income children (9-12 years) Measured BMI according to 95th Self-esteem SPPC No
percentile
Wu et al., 2014 (50) Longitudinal n 5 53 obese, n 5 32 normal-weight children Measured BMI according to 95th Social support SSSC Yes, lower levels of perceived social support in the
(8-16 years) percentile obese participants
Adolescents and adults
Faith et al., 1998 (51) Cross-sectional 4 large surveys among African American Self-report, different methods for BMI Self-esteem RSE No, among African Americans no self-esteem impairment
adolescents 12-21 years old and African classification reported
American adults
Adults
Abiles et al., 2010 (52) Cross-sectional n 5 50 obese and n 5 25 normal-weight adult Help-seeking participants from a Self-esteem RSE Yes, lower levels of self-esteem in the obese participants
participants bariatric surgery program
Brauhardt et al., Cross-sectional n 5 26 obese, 26 obese and binge-eating, and Self-reported BMI  30 Self-esteem RSE Yes, lower levels of self-esteem in the obese participants
2014 (53) 26 normal-weight adult participants
Carr et al., 2005 (54) Cross-sectional n 5 3,437 adult participants Self-reported BMI  30 Self-acceptance 3-items Yes, lower levels of self-esteem in the obese participants
H€orchner et al., 2002 (55) Cross-sectional n 5 94 female obese participants; results Help-seekers for obesity treatment, BMI Coping UCL Yes, less active coping pattern in the obese participants;
compared to normal-weight sample range 32-64 higher passive/depressive response patterns
Miller et al., 1995 (56) Experimental n 5 77 obese, n 5 78 non-obese women Self-report  20% over midpoint of Coping---Compensation Self-rating adjectives Yes, obese women rated themselves more likable and
average weight (MLIC tables) socially skilled compared to non-obese women
Ryden et al., 2003 (57) Longitudinal n 5 2,231 patients followed after weight loss Measured; no specific BMI cut points Coping OC Yes, successful weight loss yielded decreased
intervention (comparing participants with emotion-focused coping and distress and increased
successful weight loss) problem-focused coping
van Zutven (2014) (58) Cross-sectional n 5 445 obese, n 5 1,989 non-obese Self-reported BMI  30 Social support Functional perceived Yes, lower social support in the obese individuals
support
Group-specific processes
Children
Fonseca et al., 2009 (59) Cross-sectional n 5 6,131 adolescents (11-16 years) Self-reported BMI according to Cole Appearance One item, no scale Yes, negative attitude toward their appearance reported
(2000)2 by obese participants
Goldfield et al., 2010 (33) Cross-sectional n 5 1,490 adolescents (grades 7-12) Measured BMI according to 95th Body esteem BESAA Yes, lower levels of body esteem in the obese
percentile participants
Shin et al., 2008 (42) Cross-sectional n 5 413 children (grades 5-6) Measured BMI according to  95th Self-esteem, body SPPC Yes, lower levels of self-worth and higher levels of body
percentile dissatisfaction dissatisfaction in the obese participants
Adults
van Zutven (2014) (58) Cross-sectional n 5 445 obese, n 5 1,989 non-obese Self-reported BMI  30 Weight concern EDE-Q sub-scale Yes, higher levels of weight and shape concerns in the
obese participants

a
According to Dutch growth charts.
b
Reference: (60).
c
Reference: (62).
d
Reference: (63).
BESAA, Body Esteem Scale for Adolescents and Adults; CDC, Centers for Disease Control and Prevention (61); CDI, Child Depression Inventory; EDE-Q, Eating Disorder Examination Questionnaire; EDI-3, Eating Disorder Inventory; LAWSEQ,
Lawrence Self-Esteem Questionnaire; MLIC, Metropolitan Life Insurance Company; MOS-SSS, Medical Outcomes Study Social Support Survey; OC, Obesity Coping; PCSC, Perceived Competence Scale for Children; PHCSCS-2, Piers-Harris
Children’s Self-Concept Scale; RSE, Rosenberg Self-Esteem Scale; SPPC, Self-Perception Profile for Children; SSSC, Social Support Scale for Children; UCL, Utrecht Coping List; WGOC, Working Group on Obesity in China (62); WHO, World
Health Organization (63).
Obesity
Three studies show elevated levels of body dissatisfaction in chil-
dren with obesity (33,42,59). One study showed the same associated
in adults (58). Fonseca et al. operationalized body dissatisfaction by
asking whether the respondents thought they were “not very good
looking” or “not good looking at all.” These categories were col-
lapsed and revealed a significantly higher proportion of body dissat-
isfaction in adolescent with obesity. These respondents also showed
higher levels of unhappiness (59). Appearance esteem was assessed
in the study by Goldfield et al., including questions such as “I like
what I look like in pictures.” Again, adolescent with obesity were
more dissatisfied with their looks as well as with their weight status
(33). Shin et al. demonstrate an association of negative body image
and obesity in a South Korean sample. In the study in an adult sam-
ple, weight and shape concerns were included for the assessment
and thus higher in individuals with obesity (42).
Mediated effect of weight and psychopathology
Table 2 summarizes the studies that report the mediating effect of
psychosocial risk factors on psychopathology. Six studies in children
and adolescents and six studies in adults were found in the search.
Due to the limited number of studies, psychological risk factors and
group-specific processes are reported together. All report positive
evidence for the mediation of the association weight status or vic-
timization and mental health outcomes through psychological risk
factors and group-specific processes. Two studies in children (68,70)
present results that can be interpreted as potential mediation effects
without explicitly testing for true mediation. Self-esteem, coping,
and social isolation are psychological risk factors that have been
positively evaluated as mediators. Group-specific processes that
have been investigated include body dissatisfaction and internalized
stigma. One study (74) also attempts to test an additional pathway
of the mediation model and has therefore been included. The authors
hypothesize internalized stigma as the independent variable. Core
self-evaluation here mediates the effect of internalized stigma on
impaired mental health outcomes (depression as well as general anx-
iety disorder).
Discussion
This literature search aimed to review studies that investigate group-
specific processes in individuals with obesity and the prevalence of
psychological risk factors compared to normal-weight participants. It
also included studies that considered these two components as
potential mediators between weight status and/or discrimination and
psychopathology such as depression and anxiety.
It becomes evident that the number of studies on these topics is
scarce and limited to certain dimensions of psychological processes.
Psychological risk factors
Self-esteem. The best evaluated association of obesity and psy-
chosocial aspects is seen for self-esteem, with most studies estab-
lishing a negative association of weight and self-esteem in children
and adults. Based on the identity threat theory, this association is
valid since the perceived devaluation based on a certain feature
(e.g., obesity) also devaluates the self. We find some studies that do
not show an association of obesity and self-esteem and need to con-
sider ethnic and cultural aspects. The specific influence of ethnicity
272 Obesity | VOLUME 23 | NUMBER 2 | FEBRUARY 2015
A Framework for Internalized Weight Stigma Sikorski et al.
on self-esteem has been described in the past in regard to comparing
self-esteem between different ethnic groups. There, it was shown
that African American participants actually displayed higher self-
report levels of self-esteem despite belonging to a highly stigmatized
ethic group (76). In general, authors propose to move the focus on
self-esteem to the variability that is seen within stigmatized groups
or even individuals based on situational context (21)—a step still to
be taken in weight stigma.
Coping. Coping strategies were also addressed by some studies.
Most of the literature in this field, however, has been conducted in
obese-only samples (77,78). Research there shows that the coping
strategy of confirmation (e.g., eventually internalizing the expected
stereotypes of the general public), which may also be considered a
form of internalized stigma, to be closely linked to low self-esteem
but also increases in depression (for a review see ref. 77). Given the
results of the studies in the adult population, there is evidence that
certain aspects of emotional coping increase with weight, while
problem-focused coping decreases. Considering the assumption that
emotional coping is often applied when dealing with unchangeable
situations these results may reflect a general surrender of individuals
with obesity. This is strictly hypothetical, however, and will need to
be the focus of future studies. Results of one study gives some sup-
port, already, however, as emotional coping increased in participant
experiencing frustrating weight re-gain (57).
Social support. Social relations and their role in the development
and persistence of obesity have received growing research attention
(79). There are different approaches to explain the importance of
social relations in obesity. A first concentrates on social networks
that represent a web of social relationships. Results from the Fra-
mingham Heart Study were groundbreaking for this approach. In
2007, Christakis and Fowler performed a network analysis in this
large longitudinal cohort study and showed that the chances of
becoming obese increased if friends or partners became obese (80).
Their results underline the central role of network approaches in
population health. On another note, social support, that includes
instrumental, financial, and emotional forms of support, is defined
as an inter-personal mechanism that is associated with individual
health (81). Contrary to the sexual minority stigma, we find few
studies with mixed results regarding the assumption that minorities
experience lower social support per se. Research, however, shows
the importance of social support in the increase of physical activity
(82), and weight loss including social support groups (83). A theo-
retical model emphasizes different kinds of social support, poten-
tially explaining the results of this review. Verheijden et al. differen-
tiate structural (potentially available supporters) from functional
(perception of support) social support and conclude that functional
support shows a stronger correlation to health outcomes (84). Except
for one, the studies included in this review assessed structural social
support and indicate that more research is needed in this area.
Group-specific processes
This review proposes to view body image as a group-specific proxi-
mal stressor in obesity. Based on distal stigma and discrimination
experiences, body dissatisfaction may be considered a form of inter-
nalized stigma (applying the undesirable attribute “ugly” to them-
selves). A close association of weight stigma and body dissatisfac-
tion has been proposed in children for instance (85). Since body
image was not included as a search term a priori in this review, we
www.obesityjournal.org
 TABLE 2 Psychological risk factors as mediators of the association between obesity and/or stigma and psychopathology
Review

Results
consistent
Citation Design Sample Determination of obesity Stressor/status Mediator(s) Outcome with mediation?

www.obesityjournal.org
Children
EPIDEMIOLOGY/GENETICS

Adams et al., 2008 (66) Longitudinal n 5 1,287 adolescents Self-reported BMI according to CDC Victimization/bullying Self-concept for physical Depressive symptoms, Yes, but only in girls
(12/13 years old) appearance (self-like) CES-D
Ali et al., 2010 (67) Cross-sectional n 5 13,454 adolescents Measured BMI according to CDCc Perceived weight status Self-esteem Depressive symptoms, Yes
(11 to 18 years old) CES-D
deSmet et al., 2014 (68) Cross-sectional n 5 102 obese and Help-seeking obese adolescents, BMI Victimization/bullying Self-esteem Suicidal ideation Yesa
normal-weight according to WHO (2007)
adolescents
(mean age 5 15)
Martyn-Nemeth et al., Cross-sectional n 5 101 adolescents Self-reported BMI according to CDC Weight status Self-esteem Depression, Kandel Yes
2012 (37) (14-18 years) (85th percentile) Depressive Mood
scale
Mond et al., 2011 (69) Longitudinal n 5 806 participants Self-reported BMI according to CDC Weight status Body dissatisfaction Depression, Kandel Yes
interviewed in early and Depressive Mood
late adolescence scale
Sjoberg et al., 2005 (70) Cross-sectional n 5 4,703 adolescents Self-reported BMI according to Cole Weight status/shaming Social isolation Depression, DSM-IV Yesa
(15-17 years) (2000)
Adults
Crocker et al., 1993 (71) Experimental n 5 27 overweight, n 5 31 Self-reported 15 pounds overweightb Weight status Coping through Depressive symptoms, Yes
normal-weight female confirmation/ MAACL
college students self-acceptance
Durso et al., 2012 (72) Cross-sectional n 5 415 adults, 35.7% Self-report Discrimination Internalized stigma Eating disturbances Yes
obese experiences
Friedman et al., Cross-sectional n 5 110 adults Help-seeking participants in weight Weight status Body image satisfaction Depressive symptoms, Yes
2002 (73) control facility BDI
Hilbert et al. (2014) (74) Cross-sectional n 5 1,158 (19.6% obese) Self-reported BMI  30 Weight bias Core self-evaluation Depression, PHQ-2; Yes
internalization general anxiety
disorder, GAD-2
Lo et al., 2011 (75) Cross-sectional n 5 78 obese, n 5 65 Help-seeking participants in mental Weight status/ Self-esteem Binge eating disorder, Yes
non-obese mental health health care service, BMI  30 interpersonal BES
patients problems
van Zutven (2014) (58) Cross-sectional n 5 445 obese, n 5 1,989 Self-reported BMI  30 Weight status Weight/shape concerns Psychological distress, Yes
non-obese K-6

BDI, Beck’s Depression Inventory; BES, Binge Eating Scale; CDC, Centers for Disease Control and Prevention; CES-D, Center for Epidemiological Studies Depression Scale; DSM-IV, Diagnostic and Statistical Manual
of Mental Disorders, 4th Edition; GAD-2, General Anxiety Disorder short form; K-6, Kessler psychological distress scale; MAACL, Multiple Affect Adjective Check List; PHQ-2, Patient Health Questionnaire short form.

Obesity | VOLUME 23 | NUMBER 2 | FEBRUARY 2015

a
Analyses did not specifically test for mediation, but the authors conclude a potential mediation effect.
b
According to ideal weight of 100 pounds 1 5 pounds for every inch in height over 5 feet.
c
Reference: (61).
Obesity

273
Obesity
have to rely on additional studies that have been reviewed by other
authors to summarize the scientific evidence in this field. As
Schwartz and Brownell summarize, not all individuals suffer from
poor body image equally (65). One association that these authors find
is an increase prevalence of body dissatisfaction in individuals experi-
encing frequent stigmatization and discrimination. Other studies indi-
cate that a poor body image is associated with a higher risk for
depression (86) and other disorders, such as eating disturbances (87).
Psychological risk factors and group-specific
processes as mediators between stigma and
mental health outcomes
This review also shows a lack of studies investigating mediating
effects of psychological aspects in obesity and obesity discrimina-
tion. This is, however, of great importance, as perceived weight dis-
crimination has been shown to be associated with subsequent weight
gain (88). There is also evidence that weight discrimination also
mediates the risk for increased psychological distress among for-
merly overweight individuals (89). The same has been shown in
children and adolescents (90). Perceived weight discrimination may,
mediated by psychosocial processes and subsequent psychopathol-
ogy, be one driver of weight gain and unsuccessful weight loss
attempts. There is evidence for some aspects of this association:
Depression in men predicted weight gain 10 years afterwards (91)
and likewise lower self-esteem is associated with weight gain (92).
In children, studies indicate that obesity predicts lower self-esteem,
potentially being linked to later life psychological disorders (44). In
contrast to minority stress stigma, we also find eating disorders dis-
cussed as an outcome that may be affected by discrimination. As up
to 30% of individuals with obesity suffer from Binge Eating Disor-
der (93), this is an important finding that will need further
investigation.
Further studies to thoroughly investigate this association are needed
as these findings hold important implications for intervention. If we
consider weight discrimination a stressor and potential trigger for
elevated psychological risk factors and subsequent psychological
disorders and potential weight gain, all weight loss interventions
will have to consider these aspects in their program (94). So far,
psychotherapeutic aspects in obesity treatment focus on self-control,
life-style changes, and goal setting in terms of a complementary
intervention (95), but our findings indicate that general psychologi-
cal aspects as well as discrimination specific proximal stressors will
have to be in focus of the interventions just as much.
This conclusion also holds true if the assumption of a moderation
effect in psychological processes is considered. A moderation in this
context would imply that these features or traits are present in indi-
viduals with obesity prior to developing obesity (96) and there is
some research that supports this assumption as well (e.g., see ref.
97). In this case, perceived weight discrimination would be exacer-
bated based on these elevated psychological processes. The thera-
peutic consequence, however, remains the same—altering and
addressing these elevated psychological processes.
In summary, we find a decent amount of evidence supporting our
hypotheses. Some constructs, such as self-esteem, have been eval-
uated in more detail than others, but there is a growing amount of
research providing evidence for the complex association and interac-
274 Obesity | VOLUME 23 | NUMBER 2 | FEBRUARY 2015
A Framework for Internalized Weight Stigma Sikorski et al.
tion of weight stigma and psychopathological outcomes in individu-
als with obesity.
Limitations
This study only reviews studies that included a non-obese control
group or were able to draw conclusions by comparing normal-
weight individuals and individuals with obesity. Also, during the
review process, it became evident that many studies were conducted
in obese samples with co-morbidities, such as polycystic ovary syn-
drome. These samples were excluded in the current review, poten-
tially limiting generalizability. Another limitation of this review is
that we cannot rule out publication bias since we were only able to
include published work. Additionally, the review of different media-
tors poses a challenge of its own. Ideally, specific reviews for each
mediating variable are available; however, due to the limited amount
of evidence, the approach of one integrative review was pursued.
Future studies will provide a larger body of evidence for each of the
domains and will then allow for more in depth analyses of the pro-
posed mediation framework.
The limited number of studies and constructs covered in them obvi-
ously does not allow for a complete establishment of the proposed
mediation framework. An important indication is given, neverthe-
less, that elevated psychological risk factors are existent in individu-
als with obesity and they may be a mediator of weight discrimina-
tion. Future research will have to further investigate these
mechanisms as well as internalized stigma as a mediator for
impaired health outcomes.O
Acknowledgments
Authors would like to thank Mark Hatzenbuehler for his valuable
comments and advice in drafting this manuscript.
Copyright V
C 2014 The Obesity Society
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