Social Science & Medicine 161 (2016) 55e60

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Social Science & Medicine

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Short communication

Weight-related stigma is a significant psychosocial stressor in

developing countries: Evidence from Guatemala
Joseph Hackman*, Jonathan Maupin, Alexandra A. Brewis
School of Human Evolution and Social Change, Arizona State University, United States

a r t i c l e i n f o a b s t r a c t

Article history: Weight-related stigma is established as a major psychosocial stressor and correlate of depression among
Received 6 January 2016 people living with obesity in high-income countries. Anti-fat beliefs are rapidly globalizing. The goal of
Received in revised form the study is to (1) examine how weight-related stigma, enacted as teasing, is evident among women
17 May 2016
from a lower-income country and (2) test if such weight-related stigma contributes to depressive
Accepted 20 May 2016
Available online 22 May 2016
symptoms. Modeling data for 12,074 reproductive-age women collected in the 2008e2009 Guatemala
National Maternal-Infant Health Survey, we demonstrate that weight-related teasing is (1) experienced
by those both underweight and overweight, and (2) a significant psychosocial stressor. Effects are
Keywords:
Obesity
comparable to other factors known to influence women’s depressive risk in lower-income countries, such
Stigma as living in poverty, experiencing food insecurity, or suffering sexual/domestic violence. That women’s
Psychological stress failure to meet local body normsdwhether they are overweight or underweightdserves as such a strong
Guatemala source of psychological distress is particularly concerning in settings like Guatemala where high levels of
Depression over- and under-nutrition intersect at the household and community level. Current obesity-centric
Weight-stigma models of weight-related stigma, developed from studies in high-income countries, fail to recognize
that being underweight may create similar forms of psychosocial distress in low-income countries.
© 2016 Elsevier Ltd. All rights reserved.

1. Introduction
Depressive disorders are a leading cause of the global burden of
disease (Ferrari et al., 2013), and seem likely to remain so for at least
the next generation (Bromet et al., 2011; Le
pine and Briley, 2011).
While rates of depression vary from country to country, high levels
of symptoms are seen in developed and developing countries alike,
with womendespecially during their reproductive
yearsdconsistently at higher risk overall (Grigoriadis and Erlick
Robinson, 2007).
Based on studies from Anglophone countries, women’s body
size seems to matter for depression. Obesity in particular is well-
established as a major predictor (Scott et al., 2008; Luppino et al.,
2010), with women at highest body weights at greatest risk
(Chen et al., 2007; Hilbert et al., 2014). While part of this risk may
be related to functional challenges of living with chronic disease
(Moussavi et al., 2007), the stigma of obesity itself seems to be a
major contributor (Myers and Rosen, 1999; Carpenter et al., 2000;
* Corresponding author. SHESC 233, P.O. Box 872402, Tempe, AZ 85287-2402,
United States.
E-mail address: jhackman@asu.edu (J. Hackman).
Friedman et al., 2008; Puhl and Heuer, 2010; Tomiyama, 2014).
Stigma in this context refers to the process by which arbitrary
moral judgments (e.g., “lazy”) become attached to body size,
leading to social discrediting, rejection, and marginalization
(Brewis, 2014). Obesity-related stigma is increasingly recognized as
a major social and economic challenge to millions in places such as
the U.S. and U.K., resulting in multiple interpersonal and structural
mistreatments and discriminations from poorer health care to a
systematic wage gap (Carr and Friedman, 2005; Puhl and Heuer,
2009) in addition to the more proximate individual-level effects
of distress, stress, and social withdrawal and exclusion. Teasing (our
focus herein) is an especially powerful way that such obesity stigma
is enacted, not just by strangers but also by family and friends (e.g.,
Taylor, 2011).
Recent research has established that obesity-related stigma is
increasingly reported in many lower-income, developing countries
throughout the globe (Brewis, 2011; Brewis and Wutich, 2014;
Council and Placek, 2014), a concerning trend that seems to have
emerged and accelerated over the last decade. The goal here is to
identify if weight-related stigma may also be an emergent
contributor to depressive symptoms in lower-income countries, as
it is already known to be in high-income ones. Given the growing

http://dx.doi.org/10.1016/j.socscimed.2016.05.032
0277-9536/© 2016 Elsevier Ltd. All rights reserved.
56 J. Hackman et al. / Social Science & Medicine 161 (2016) 55e60

burden of depression and related mental illness in developing Table 1

countries, the emergence of weight-related stigma as a new, Sample descriptives and distribution of weight-related stigma by predictor.

culturally-based source of psychosocial distress would be Distribution of Percent

extremely concerning. Women in many developing countries variables experienced
already struggle with other psychosocial stressors that are known weight-related
teasing
triggers for depression, such as coping with food insecurity (Hadley
and Patil, 2008; Weaver and Hadley, 2009), social inequalities N % % P-value

(Patel, 2001; Lorant et al., 2003; Alvarado et al., 2007; Cifuentes Residence
et al., 2008), chronic disease (Moussavi et al., 2007), or domestic Urban 5148 42.6 11.5 0.08
Rural 6926 57.4 10.5
and sexual violence (Fischbach and Herbert, 1997; Campbell, 2002;
Ethnicity
Ellsberg et al., 2008); belonging to a marginalized social group Ladina 6099 50.5 12 <0.001
(Karlsen and Nazroo, 2002; Williams et al., 2003); and living Indigenous 5975 49.5 9.8
around armed conflict (Murthy and Lakshminarayana, 2006; Miller Relationship status
and Rasmussen, 2010; Panter-Brick, 2010; Pike et al., 2010). Married 10,817 89.6 10.7 0.03
Single 1257 10.4 12.7
Guatemala is an excellent case to consider. While there are few
Age category
studies of mental health in this low-income Central American 15e20 1077 8.9 10.8 <0.001
country, a 2009 national survey found that 27.8% of Guatemalans 20e25 2082 17.2 11.4
suffer from mental health disorders, with post-traumatic stress 25e30 2637 21.8 12.4
(6.9%) and depression (6.4%) among the most common (Lo
pez, 30e35 2374 19.7 11.6
35e40 1786 14.8 9.9
2009). In addition, more women than men suffer from mental 40e45 1201 9.9 8.7
health disorders. Given the typical under-reporting of mental 45e50 917 7.6 8.4
health disorders (Kohn et al., 2005), these rates reflect a real and Wealth quintile
poorly documented health burden in Guatemala. Recent studies 1 (Lowest) 2687 22.3 9.3 0.04
2 2635 21.8 11.2
have focused on the impact of violence on mental health, particu-
3 2507 20.8 11.7
larly the relationship between experiences during the 36-year civil 4 2474 20.5 11.6
war and prevalence of post-traumatic stress disorder (Polanco 5 (Highest) 1771 14.7 10.7
et al., 2012; Branas et al., 2013). In addition to high rates of BMI classes
<18.49 349 2.9 15.5 <0.001
contemporary and historical violence that disproportionately affect
18.5e24.90 4765 39.5 10.8
rural and indigenous populations (Miller, 1996; Sabin et al., 2006; 25e29.90 4478 37.1 8.7
Foxen, 2010), Guatemala exhibits several factors known to 30þ 2482 20.9 14.4
contribute to mental illness, including high rates of food insecurity Food insecurity
(Chaparro, 2008), pervasive social and economic discrimination Food secure 5002 41.4 9 <0.001
Moderately insecure 5040 41.7 11.5
(Bruni et al., 2009; Gindling and Trejos, 2013), increasing rates of
Severely insecure 2032 16.8 14
gender-based violence (Carey Jr. and Torres, 2010; Ogrodnik and Domestic or sexual violence
Borzutzky, 2011; Halvorsen, 2014), and a decades-long civil war Yes 1239 10.3 22.3 <0.001
(Miller, 1996; Sabin et al., 2006; Foxen, 2010). No 10,835 89.7 9.6
Additionally, obesity rates (BMI
30) among women aged Chronic health problem
Yes 1027 8.5 10.6 <0.001
15e49 have nearly doubled in the last 20 years, from 8.0% in 1995 to No 11,047 91.5 14.4
15.4% in 2009 (INE, 2011). Obesity risk in Guatemala is compounded Weight-related teasing
by high rates of childhood malnutrition (De Onis, Monteiro et al., Yes 1315 10.9 e e
1993; De Onis, Blo €ssner et al., 2012) and food insecurity (Melgar- No 10,759 89.1 e e
~ onez, 2010), both of which increase risk of excess weight Psychological distress
Quin
No distress 4152 34.4 5 <0.001
gain in adulthood (Hoffman et al., 2000; Gluckman and Hanson, Mild distress 4026 33.3 10.6
2004; Morales-Rua
n et al., 2014). These so-called ‘dual burden’ Moderate-to-severe 3896 32.3 17.5
rates of malnutrition and obesity are higher in Guatemala than p-values based on Chi-square tests of independence.
most other studied countries (Jehn and Brewis, 2009). There is little
information about weight stigma in Guatemala, although some
research among schoolchildren demonstrates stigma against both 2. Methods and materials
obese and underweight bodies, with the latter exacerbated by ex-
periences of food insecurity (Maupin and Brewis, 2014). In this 2.1. Psychological distress
paper, we examine the distribution of women’s experience of
weight-related teasingda proxy for the social enactment of stig- The ENSMI 2008e2009 contained nine items related to the
madacross different body sizes and test if it has any apparent ef- frequency of experiencing symptoms of psychological distress
fects on depressive symptoms in Guatemalan women, taking into within the last four weeks (Table S1), scaled from 0-never to 3-
account body size, as well as other factors already known to impact always, summed to a score out of 27. This score was collapsed
depression among women in developing countries. into three categories, with scores of 0e3 indicating little or no
Data are from the 2008e2009 nationally representative psychological distress, 3e9 mild distress, and 9e27 moderate-to-
Guatemala National Maternal-Infant Health Survey (Encuesta severe distress. Analysis using alternative cut-points did not qual-
Nacional de Salud Materno Infantil or ENSMI) (INE, 2011). Our final itatively change the results and is presented in the supplemental
analytic sample includes 12,074 of the 16,819 women who materials (Supplemental Materials Table S5).
completed interviews (Table 1). The major reason for exclusions
was because of missing data on domestic abuse/sexual violence
(N ¼ 4264). Analyses without this exclusion criteria and a larger 2.2. Weight-related teasing
sample are provided in the supplemental materials (Supplemental
Materials Table S6). The ENSMI asked respondents: “¿El peso que tiene actualmente
 J. Hackman et al. / Social Science & Medicine 161 (2016) 55e60
le ha provocado: burlas, ofensas o situaciones molestas?”(Has the
weight that you currently have provoked teasing, insults, or up-
setting situations?). Any report was coded as 1, no report as 0.
2.3. Body size
Measured height and weight was used to calculate Body Mass
Index (BMI). BMI was categorized into standard World Health Or-
ganization categories of underweight, normal weight, overweight,
and obese.
2.4. Wealth quintile
Being resource poor is a known predictor of depression (Lund
et al., 2010; Tampubolon and Hanandita, 2014), especially where
inequities in wealth are apparent (Muramatsu, 2003; Wilkinson,
2005; Wilkinson and Pickett, 2007). Using principal component
analysis on owned household items, we created a ‘relative wealth
index’ grouped into quintiles (Filmer and Pritchett, 2001).
2.5. Food insecurity
Guatemala has high rates of food insecurity (Chaparro, 2008;
Melgar-Quin ~ onez, 2010). Five yes/no questions (see Chaparro,
2008) were used to distinguish food secure (0e1 score), moder-
ately food insecure (score 2e3), and severely food insecure (score
4e5) women.
2.6. Experience of domestic or sexual violence
Women were asked if their partner or spouse had committed
acts of sexual or domestic violence over the last 12 months. Listed
offenses ranged from being slapped, kicked, and beaten, to threats
with a deadly weapon and forced intercourse. Any report was
coded as 1, no report as 0.
2.7. Health status
Respondents over 30 years of age were asked if they suffered
from a list of chronic diseases or acute episodes that included
diabetes, hypertension, stroke, osteoporosis, cancer, or heart attack
or myocardial infarction. Participants reporting a chronic health
problem were coded as 1, otherwise as 0. Analyses using dummy
codes for each health problem did not qualitatively change the
results (Supplemental Materials Table S4).
Other variables included in the model as covariates included
rural residence, age binned into 5-year increments, current preg-
nancy status, current marital status, and ethnicity.
3. Analyses
First, we examined the distribution of weight-related teasing
across body size categories and other predictors using a chi-square
test and logistic regression. Second, we assessed the association
between weight-related teasing and psychological distress using a
multinomial logistic regression with self-reports of experiences of
weight-related teasing as the key predictor of interest and the
categorical level of psychological distress as the outcome measure.
We examined the unadjusted effects of each predictor in a baseline
model to identify the raw association between the predictor and
psychological distress. Baseline models included age, rural resi-
dence, pregnancy status, marital status, and ethnicity as covariates.
We then included all predictors in a full model to assess strength of
weight-related stigma relative to other predictors of psychological
distress. Finally, we calculated odds ratios of depression
57
classification using a subset of the data where participants were
matched according to propensity scores for experiencing teasing.
4. Results
Weight-related teasing showed a curvilinear relationship with
body size, with those classified as underweight and obese more
likely to report teasing (Fig. 1). Weight-related teasing was signif-
icantly more frequent among non-indigenous (Ladino) women,
those with more chronic health problems, those reporting sexual or
domestic violence, younger women, those living with food inse-
curity, and those living in poorer households (Table 1). The results
from the multivariate logistic regression showed the same patterns
(Supplemental Materials Table S2)
Table 2 reports the relative risk ratios from the multinomial
logistic regression. The baseline model showed psychological
distress is strongly predicted by each of the main predictors, food
insecurity, experience of sexual/domestic violence, chronic health
problems, and weight-related stigma. Body size showed little as-
sociation with psychological distress. Wealth quintile showed a
relatively uniform effect on psychological distress when compared
to the wealthiest quintile. Psychological distress also showed a
positive association with age, was higher among pregnant and
single women, and showed a slight effect of ethnicity.
Results from the full model show those reporting weight-
related teasing to be 2.1 times more likely to report mild distress
and 3.7 times more likely to report moderate-to-severe distress
(see Fig. 2). The relative risk ratio of weight-related stigma on
moderate-to-severe distress is slightly less than experience with
severe food insecurity (4.7), comparable to the effect of sexual/
domestic violence (3.8), and slightly larger than experiencing a
chronic health problem (3.2) or moderate food insecurity (2.4). An
interaction term between teasing and body size showed the effect
of weight-related teasing on psychological distress did not differ by
body size (Supplemental Materials Table S3).
In the full model, body size had a slight positive effect on
moderate-to-severe psychological distress (1.2 times more likely
for overweight), but was otherwise a non-significant factor. Wealth
quintile showed a similar slight effect but was inconsistent across
mild and moderate-to-severe distress. Psychological distress also
showed a positive association with age, and was higher among
pregnant and single women.
The results from the multinomial logistic regression were sup-
ported by the propensity score analysis (Supplemental Materials
25.0%
Percent Reporting Weight-Related Teasing
20.0%
15.0%
10.0%
5.0%
0.0%
<18.5 18.5-24.9 25-29.9 30+
BMI Catagory
Fig. 1. Proportion of women reported experiencing weight-related teasing by BMI
Category. Error bars represent 95% C.I.
58 J. Hackman et al. / Social Science & Medicine 161 (2016) 55e60

Table 2
Relative risk ratios from the multinomial logistic regression.

Baseline model Full model

Mild stress Moderateesevere stress Mild stress Moderateesevere stress

Relative risk 95% C.I. Relative risk 95% C.I. Relative risk 95% C.I. Relative risk 95% C.I.

Main predictors
Moderate food insecurity 1.5*** (1.4, 1.7) 2.5*** (2.3, 2.8) 1.6*** (1.4, 1.7) 2.4*** (2.2, 2.7)
Severe food insecurity 1.7*** (1.5, 2) 5*** (4.4, 5.7) 1.8*** (1.5, 2.1) 4.7*** (4, 5.5)
Experience with violence 2.2*** (1.9, 2.7) 4.7*** (4, 5.5) 2.1*** (1.7, 2.5) 3.8*** (3.2, 4.5)
Health problem 2.2*** (1.8, 2.7) 3.4*** (2.8, 4.1) 2.1*** (1.7, 2.6) 3.2*** (2.6, 3.9)
Weight related stigma 2.3*** (2, 2.8) 4.4*** (3.8, 5.2) 2.1*** (1.8, 2.5) 3.7*** (3.1, 4.4)
Body size
BMI <18.5 1 (0.8, 1.3) 1.1 (0.9, 1.5) 1 (0.8, 1.3) 1.1 (0.8, 1.4)
18.5e24.9y e e e e e e e e
25e29.9 1 (0.9, 1.1) 1.1* (1, 1.2) 1 (0.9, 1.1) 1.2** (1, 1.3)
30e34.9 1.1* (1, 1.3) 1.1 (1, 1.3) 1.1 (0.9, 1.2) 1.1 (0.9, 1.2)
Wealth quintile
1 (Lowest) 1.1 (0.9, 1.3) 1.9*** (1.6, 2.3) 0.8* (0.7, 1) 1 (0.8, 1.2)
2.00 1.2* (1, 1.4) 2*** (1.7, 2.4) 1 (0.8, 1.1) 1.2 (1, 1.4)
3.00 1.2* (1, 1.4) 1.8*** (1.6, 2.2) 1 (0.9, 1.2) 1.2* (1, 1.4)
4.00 1.2** (1.1, 1.4) 1.5*** (1.2, 1.7) 1.1 (1, 1.3) 1.2 (1, 1.4)
5 (Highest)y e e e e e e e e
Covariates
Age category 1.1*** (1.1, 1.2) 1.3*** (1.2, 1.3) 1.1*** (1.1, 1.1) 1.2*** (1.2, 1.3)
Rural residence 0.9* (0.8, 1) 1.1 (1, 1.2) 0.9 (0.8, 1) 1 (0.9, 1.1)
Pregnant 1.3** (1.1, 1.5) 1.3** (1.1, 1.5) 1.4*** (1.2, 1.6) 1.5*** (1.2, 1.8)
Single 1.3** (1.1, 1.5) 2*** (1.7, 2.3) 1.2* (1.1, 1.4) 1.9*** (1.6, 2.2)
Indigenous 1 (0.9, 1.1) 1.2** (1.1, 1.3) 1 (0.9, 1.1) 1 (0.9, 1.1)

Baseline model included the independent predictor plus all covariates. y Reference category, *p < 0.05, **p < 0.01, ***p < 0.001.

Mild Distress Moderate-Severe

Distress

Main Predictors
Moderate Food Insecurity
Severe Food Insecurity
Sexual/Domestic Violence
Health Problem
Weight-Related Teasing
Body Size
Underweight
Overweight
Obese
Wealth Quintile
Wealth Quintile 1
Wealth Quintile 2
Wealth Quintile 3
Wealth Quintile 4
Covariates
Age
Rural
Pregnant
Single
Indigenous

0 1 2 3 4 5 6 0 1 2 3 4 5 6

Fig. 2. Multinomial logistic regression estimates of mild and moderate-severe psychological distress. Plots show relative risk ratios (exponentiated coefficients) and 95% CIs from
the full model.

S7). In a subset of women who were matched on all covariates used
in the full model (N ¼ 2438), women who reported experiencing
weight-related teasing were 2.1 (95% C.I. 1.7e2.6) times more likely
to be classified as mild distress and 3.0 (95% C.I. ¼ 2.4e3.7) times
more like to be classified as moderate-severe distress
(Supplemental Materials Table S7-S8).
5. Discussion and conclusion
Our analysis shows that weight-related teasing is frequently
reported by reproductive-age Guatemalan women. This finding
adds to a growing body of evidence that weight-related stigma is
now a truly global/ized phenomenon (Anderson-Fye and Brewis,
2017). Importantly, risk of teasing is higher in women who are
already vulnerable in other waysdthose who are younger, poorer,
and less food secure.
An advantage of our approachdmodeling a large representative
sample of womendis the capacity to disentangle the effects of
weight-related teasing from other known drivers of women’s
depression that would be expected in low-income settings like
Guatemala, and compare its effect level. The expected factorsd-
chronic health problems, food insecurity, and recent experiences of
 J. Hackman et al. / Social Science & Medicine 161 (2016) 55e60
domestic or sexual abusedare shown here to significantly worsen
women’s depressive symptoms. Weight-related stigma, enacted as
body teasing, also proves to be a significant source of distress in
their everyday lives.
This finding is novel and important. It suggests that not only are
women in low-income countries experiencing weight-related
stigma, but that this stigma is emotionally damaging to them.
Moreover, the effects of weight-related stigma are on par with and
likely additive to other better-known drivers of women’s depres-
sion. The analysis here suggests that the stress of failing to meet
(probably rapidly changing) standards to be “just the right size”
adds to women’s psychological burdens and is potentially signifi-
cant in the etiology of depression among women in lower-income
countries. The role of stigma related to body norms is never
considered in the broader discussion of etiology and treatment of
depression in the Global South, perhaps because people struggling
with under-nutrition or food insecurity are assumed not to be
concerned with body image. The causes and consequences of
weight-related stigma in developing countries need to be engaged
as part of broader efforts to improve mental health. Improved
empirical evidence of the prevalence and impacts of weight-related
stigma will be important to this larger effort.
The observation that teasing around body weight focuses on
underweight as well as overweight is another important finding.
Our results show the effect of weight-related teasing on psycho-
logical health is similar across all body sizes. However the broader
issue uncovered here is that in Guatemala what matters is not
having a large body size per se, but rather the social demands for
women to meet body norms more generallydto be neither too fat
nor too thin. Body teasing is distressing for everyone. But women
whose body sizes fall at either end of the normal distribution of
body sizes are much more likely to be teased than those in the
middle. Hence they have more depressive symptoms.
In most prior studies of weight-related stigmadalmost all
conducted in the Global Northdthe focus has been almost entirely
on documenting the many impacts of negative judgments associ-
ated with high body weights (“too fat”). Attendant anti-weight-
stigma efforts are exclusively focused on changing judgments to-
ward people living with obesity. Our findings suggest that current
models of damaging weight-related stigma need to acknowledge
that in some cultural contexts people who are socially classified as
“too small” or “too skinny” (i.e., underweight) are also suffering
damaging weight-related stigma.
This more expansive view is especially important in countries
like Guatemala that have a long history of widespread undernu-
trition alongside a new and growing experience with obesity
(Maupin and Brewis, 2014). For example, how differently sized
bodies are portrayed and discussed in anti-obesity public health
campaigns currently rolling out across Latin America (OECD
Directorate for Employment) should be carefully considered,
especially as they often intersect with anti-undernutrition efforts
taking place concurrently (Doak, 2002; Kumanyika et al., 2002). We
also need to better understand how vulnerabilities to weight-
related exclusion and mistreatment intersect with other stressors
beyond the nutritional, such as poverty and sexual or domestic
violence. To do so, we need more data on how weight-related
stigma is differently experienced and distributed in diverse local,
national, and cross-national contexts.
Limitations of this study include a measure of distress based on
a limited number of survey items. Analyses that can more effec-
tively differentiate anxiety from depression and capture clinically-
significant levels of depression would better clarify when and how
weight-related stigma is damaging to women in low-income set-
tings. As with any observational study, we were unable to test
causal direction in the observed associations. Being depressed can
59
also heighten sensitivity to, and likelihood of reporting, weight-
related stigma (Forgas et al., 1984; Giesler et al., 1996; Peckham
et al., 2010), so it is possible that cause-and-effect could be
reversed or otherwise complicated. More longitudinal study de-
signs (Eisenberg et al., 2006) are necessary in order to test the di-
rection and impact of teasing and other manifestations of weight-
related stigma on emotional health.
Acknowledgements:
This research was supported in part by the Virginia G Piper
Charitable Trust through the Mayo Clinic/Arizona State University
Obesity Solutions initiative.
Appendix A. Supplementary data
Supplementary data related to this article can be found at http://
dx.doi.org/10.1016/j.socscimed.2016.05.032.
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