PAPER Weight-teasing among adolescents: correlations with ... - Nature

International Journal of Obesity (2002) 26, 123–131 ß 2002 Nature Publishing Group All rights reserved 0307–0565/02 $25.00 www.nature.com/ijo

PAPER Weight-teasing among adolescents: correlations with weight status and disordered eating behaviors D Neumark-Sztainer1*, N Falkner1, M Story1, C Perry1, PJ Hannan1 and S Mulert1 1

Division of Epidemiology, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA

OBJECTIVES: This study aimed to assess the prevalence of perceived weight-teasing and associations with unhealthy weightcontrol behaviors and binge eating in a population-based sample of youth. Particular focus was placed on overweight youth, who may be most vulnerable to weight-teasing. METHODS: The study population included 4746 adolescents from St Paul=Minneapolis public schools who completed surveys and anthropometric measurements as part of Project EAT, a population-based study of eating patterns and weight concerns among teens. RESULTS: There were statistically significant associations between perceived weight-teasing and weight status; both overweight and underweight youth reported higher levels of teasing than average weight youth. Very overweight youth (body mass index (BMI) 95th percentile) were most likely to be teased about their weight; 63% of very overweight girls, and 58% of very overweight boys reported being teased by their peers, while weight-teasing by family members was reported by 47% of these girls and 34% of these boys. Youth who were teased about their weight, particularly overweight girls, reported that it bothered them. Perceived weight-teasing was significantly associated with disordered eating behaviors among overweight and nonoverweight girls and boys. For example, among overweight youth, 29% of girls and 18% of boys who experienced frequent weight-teasing reported binge-eating as compared to 16% of girls and 7% of boys who were not teased. CONCLUSIONS: Many adolescents, in particular those who are overweight, report being teased about their weight and being bothered by the teasing. Weight-teasing is associated with disordered eating behaviors that may place overweight youth at increased risk for weight gain. Educational interventions and policies are needed to curtail weight-related mistreatment among youth. International Journal of Obesity (2002) 26, 123 – 131. DOI: 10.1038=sj=ijo=0801853 Keywords: adolescents; stigmatization; teasing; dieting; binge eating

Introduction Obesity is steadily increasing among children, adolescents, and adults within the United States.1 The high prevalence of obesity and its potential health consequences point to an urgent need for public health interventions aimed at its prevention. While it is important to strive towards decreasing the prevalence of obesity, it is equally important to promote the psychosocial and physical well-being of overweight individuals and ensure that they are not being mis-

*Correspondence: D Neumark-Sztainer, Division of Epidemiology, School of Public Health, University of Minnesota, 1300 South Second Street, Suite 300, Minneapolis, MN 55454, USA. E-mail: [email protected] Received 17 November 2000; revised 15 June 2001; accepted 12 July 2001

treated due to being overweight. Research has demonstrated that overweight individuals are often negatively stereotyped2 – 7 and that obesity may lead to negative social and economic consequences.8 – 10 Surprisingly little research has assessed the prevalence of weight-related stigmatization within representative community-based samples, although in a large non-clinical sample of adults participating in a weight-gain prevention program, weight-related stigmatization was found to be prevalent, particularly among overweight individuals.11 Adolescents may be particularly sensitive to weightrelated mistreatment since identity formation is a major developmental task of adolescence and body image and self-esteem tend to be intertwined. In a qualitative study in which 50 overweight adolescent girls were interviewed about their weight-related experiences, all but two of the girls described stigmatizing experiences such as name calling

Weight-teasing among adolescents D Neumark-Sztainer et al

124

and teasing.12 A number of studies have indicated that adolescent girls who are teased about their weight are more likely to display psychological, body image and=or eating disturbances.13 – 17 For example, in a study of 121 adolescent girls, Fabian and Thompson14 found that both teasing frequency and teasing effect (eg how much the teasing upset subjects) were significantly associated with body dissatisfaction, eating disturbances and depression. Furthermore, Grilo et al18 studied a clinical sample of 40 overweight female adults and found that the frequency of being teased about weight and size while growing up was correlated with body dissatisfaction in adulthood. The present study builds upon past research examining issues of weight-related mistreatment. Although weight-teasing has been discussed in the scientific literature, we are not aware of any large population-based studies examining the prevalence and potential impact of weight-teasing among adolescent girls and boys. We were interested in assessing the prevalence of perceived weight-teasing by peers and family members and the degree to which weight-teasing bothers youth, particularly overweight youth. Among overweight youth, we were interested in examining ethnic differences in weight-teasing, to see if weight-teasing is less commonly experienced among ethnic groups in which there tend to be higher prevalences of obesity and greater latitude in body size acceptance (eg among African-Americans). Finally, we were interested in examining associations between perceived weight-teasing and disordered eating behaviors (unhealthy weight control behaviors and binge eating) among overweight youth.

Methods Study population The study population included 4746 adolescents from 31 public middle schools and high schools from urban and suburban school districts in the St Paul=Minneapolis area of Minnesota. Participants were equally divided by gender (50.2% boys, 49.8% girls). The mean age of the study population was 14.9 y (s.d. ¼ 1.7); 34% were in junior high school and 65.7% in high school. The ethnic=racial background of the participants was as follows: 48.5% Caucasian, 19.0% African-American, 19.2% Asian-American, 5.8% Hispanic, 3.5% Native American and 3.9% mixed=other.

Study design Data for the present study were drawn from Project EAT (Eating Among Teens), a comprehensive study of eating patterns and weight concerns among adolescents. Survey and anthropometric data were collected from students within Health, Physical Education, and Science classrooms in one 90 min period or two 50 min periods. Surveys were completed by students within their classrooms under the direction of trained research staff. Height and weight were International Journal of Obesity

assessed by research staff within a private area in the school. Study procedures were approved by the University of Minnesota Human Subjects’ committee and by the research boards of the participating school districts. Consent procedures were done in accordance with the requests of the participating school districts; in some schools passive consent procedures were utilized while in others active consent procedures were required. The response rate for student participation was 77.1%; the main reasons for lack of participation were absenteeism and failure to return consent forms within schools requiring active consent.

Survey development The Project EAT survey is a 221-item survey assessing a range of socio-environmental, personal and behavioral factors of potential relevance to nutritional health and obesity among adolescents. A theoretical framework based on Social Cognitive Theory guided the selection of constructs to be assessed in the survey. A thorough literature search was done to identify previously utilized and tested questions to assess relevant constructs. In cases in which suitable questions were not available, existing questions were modified to meet the needs of the study or new questions were developed. The survey went through multiple revisions based upon input from a team of experts from diverse professional backgrounds, members of the University of Minnesota Youth Advisory Board, and 7th and 10th grade students who took the survey.

Measures Weight status was based on height and weight measurements taken by trained research staff in a private area near the area of survey administration. Standardized equipment and procedures were employed. Body mass index (BMI) values were calculated according to the formula: weight (kg)=height (m)2. Using gender- and age-specific cut-off points based on reference data from the Centers for Disease Control growth charts, respondents were classified as underweight (BMI < 15th percentile), average weight (BMI, 15th percentile to < 85th percentile), moderately overweight (BMI 85th to < 95th percentile), and very overweight (BMI 95th percentile).19,20 For analyses focusing on overweight youth, the categories ‘moderately overweight’ and ‘very overweight’ were grouped together. To assess frequency of weight-teasing, respondents were asked how often ‘you are teased about your weight’ as part of a series of questions assessing discrimination issues. Response categories were: (1) never; (2) less than once a year; (3) a few times a year; (4) a few times a month; and (5) at least once a week. Responses were dichotomized for some of the analyses; those who reported being teased a few times a year or more were considered to have experienced weight-teasing. Weight-teasing by peers was assessed with the question: ‘Have you ever been teased or made fun of by


other kids because of your weight?’ (yes=no). A similar question was asked to assess weight-teasing by family members. The degrees to which respondents were bothered by weight-teasing by peers and family members were assessed separately with follow-up questions. Teens were asked to indicate how much the teasing bothered them (none=a little bit=somewhat=very much). These questions were based upon survey items developed by Thompson and his colleagues21 have indicated the importance of examining the frequency of teasing, different sources of teasing (ie peers and family members), and the effect of teasing (ie how much it bothers those teased). Weight control behaviors were assessed with the question: ‘Have you done any of the following things in order to lose weight or keep from gaining weight during the past year?’ (yes=no for each method). Responses classified as unhealthy weight control behaviors included: (1) fasted; (2) ate very little food; (3) took diet pills; (4) made myself vomit; (5) used laxatives; (6) used diuretics; (7) used food substitute (powder=special drink); (8) skipped meals; and (9) smoked more cigarettes. Binge eating was assessed with the question: ‘In the past year, have you ever eaten so much food in a short period of time that you would be embarrassed if others saw you (binge eating)?’ (yes=no). Gender, school level, ethnicity=race, and socio-economic status were based on self-report. School level was divided into middle school (7th – 8th grade) and high school (9th – 12th grade). Ethnicity=race was assessed with the question: ‘Do you think of yourself as; (1) white; (2) black or AfricanAmerican; (3) Hispanic or Latino; (4) Asian-American; (5) Hawaiian or Pacific Islander; or (6) American Indian or Native American’. Youths were given the option of choosing multiple responses and those reporting more than one response (other than white) were coded as ‘mixed=other’. Due to the small number of youth reporting ‘Hawaiian or Pacific Islander’ (n ¼ 30), these youths were coded as ‘mixed=other’. The prime determinant of socio-economic status (SES) was parental educational level, defined by the higher level of educational attainment of either parent. Other variables taken into account in assessing family SES included family eligibility for public assistance, eligibility for free or reduced-cost school meals, and employment status of mother and father.

Data analysis Associations between gender and teasing revealed statistically significant differences, therefore all subsequent analyses were stratified by gender. Unadjusted associations between weight status and teasing were examined using w2 tests, and associations adjusted for SES, ethnicity and school level were conducted using logistic regression. Associations between ethnicity and teasing were examined among overweight youth using w2 tests. Among youth who reported being teased by peers or family members, percentages of youths reporting that the teasing bothered them were exam-

ined across weight status using w2 tests. Finally, associations between weight-teasing and unhealthy weight control=binge eating behaviors were examined. Unadjusted associations were examined using w2 tests and associations adjusted for BMI, SES, ethnicity and school level were examined using logistic regression. Associations between teasing and weight control=binge eating behaviors were examined among overweight youths (our primary interest) and within the total population (overweight and non-overweight youths). Although the design of Project EAT sampled from schools, analyses were done without considering school effect. The variables of interest (gender, ethnicity, teasing) are crossed with schools rather than being nested in schools so any comparison between categories of these non-nested variables removes the school component of variance. Thus, simple analyses were deemed appropriate. To conduct all analyses, SAS Release 6.12 was used.

125

Results Prevalence of weight-teasing across gender Nearly a quarter of the youths reported being teased about their weight at least a few times a year. Although reported by both genders, weight-teasing was more commonly reported by girls than boys. Weight-teasing ( few times a year) was reported by a slightly higher percentage of girls (n ¼ 564, 25.5%) than boys (n ¼ 490, 22.2%; w2 ¼ 6.7, P ¼ 0.010). Among girls, frequency of being teased about one’s weight was as follows: never (57.2%); less than once a year (17.3%); a few times a year (11.8%); a few times a month (6.9%); and at least once a week (6.8%). Among boys, frequency of being teased about one’s weight was: never (64.6%); less than once a year (13.2%); a few times a year (11.8%); a few times a month (5.8%); and at least once a week (4.6%). Weightteasing by peers (ever) was reported by significantly more girls (n ¼ 667, 30.0%) than by boys (n ¼ 546, 24.6%; w2 ¼ 16.3, P < 0.001). Weight-teasing by family members (ever) was reported by significantly more girls (n ¼ 637, 28.7%) than boys (n ¼ 356, 16.1%; w2 ¼ 101.5, P < 0.001).

Prevalence of weight-teasing across weight status Associations between weight status and weight-teasing were found to be statistically significant among girls and boys in univariate analyses (Table 1) and in analyses adjusted for sociodemographic characteristics (SES, ethnicity and school level; Table 2). High percentages of very overweight girls reported being teased by peers (63.2%) or by family members (47.2%). Relatively high percentages of underweight girls (BMI 15th percentile) reported being teased by peers (48.4%). Adjusted analyses similarly indicated that very overweight, moderately overweight, and underweight girls were at greater risk for being teased by peers about their weight than average weight girls. Moderately and very overweight girls (but not underweight girls) were at increased risk for being teased by family members. Strong associations, with International Journal of Obesity


126 Table 1 Numbers and percentages of adolescent girls and boys who report frequent weight teasing, weight teasing by peers, and weight teasing by family across weight statusa Frequent weight teasing ( few times=y) %

n

Girls Underweight (n ¼ 95) Average weight (n ¼ 1267) Moderately overweight (n ¼ 406) Very overweight (n ¼ 250)

Boys Underweight (n ¼ 116) Average weight (n ¼ 1300) Moderately overweight (n ¼ 297) Very overweight (n ¼ 333)

40 236 115 112

41 168 66 167

Weight teasing by peers (ever) %

n

%

48.4 21.2 31.4 63.2 2 w ¼ 194.9 P < 0.001

23 298 137 117

24.2 23.6 33.7 47.2

40.5 13.7 26.3 58.3 2 w ¼ 305.6 P < 0.001

16 142 49 113

n

44.0 18.7 28.5 45.3 2 w ¼ 100.6 P < 0.001

45 268 127 158

36.6 13.0 22.3 50.2 2 w ¼ 230.3 P < 0.001

47 178 78 194

Weight teasing by family (ever)

2

w ¼ 63.6 P < 0.001 13.8 11.0 16.5 34.0 2 w ¼ 107.0 P < 0.001

a Underweight (BMI < 15th percentile); average weight (15th – 85th percentile); moderately overweight (85th – 95th percentile); very overweight ( 95th percentile).

Table 2 Weight teasing among adolescent girls and boys by weight status: odds ratios (OR) and 95% confidence intervals (CI)a,b Frequent weightteasing ( few times=y) b

Weight-teasing by peers (ever)

Weight-teasing by family (ever)

OR

CI

OR

CI

2.45, 6.03 — 1.31, 2.24 2.60, 4.79

3.66 1.00 1.74 6.30

2.36, 5.66 — 1.35, 2.25 4.65, 8.71

1.10 1.00 1.80 3.29

0.66, 1.79 — 1.39, 2.32 2.43, 4.46

2.48, 5.91 — 1.48, 2.84 5.10, 8.91

4.40 1.00 2.43 9.61

2.87, 6.71 — 1.77, 3.31 7.26, 12.8

1.24 1.00 1.56 4.00

0.67, 2.15 — 1.07, 2.23 2.97, 5.39

OR

CI

Girls Underweight (n ¼ 93) c Average weight (n ¼ 1208) Moderately overweight (n ¼ 389) Very overweight (n ¼ 239)

3.86 1.00 1.71 3.53

Boys Underweight (n ¼ 106) Average weightb (n ¼ 1242) Moderately overweight (n ¼ 286) Very overweight (n ¼ 321)

3.85 1.00 2.06 6.74

a

Adjusted for socio-economic status, ethnicity and school level. Odds ratios are statistically significant (P < 0.05) when 1.0 is not included in the 95% confidence intervals; statistically significant odds ratios are in bold type. c Reference group ¼ youth of average weight (BMI 15th – 85th percentile). b

similar patterns, were found amongst boys. Very overweight boys were most likely to be teased about their weight by both peers and family members. In comparison to average weight boys, underweight boys were more likely to be teased about their weight by peers, but not by family members. High percentages of very overweight youths (BMI 95th percentile) reported being teased about their weight freInternational Journal of Obesity

quently. Among very overweight girls, 13.4% reported being teased about their weight a few times a year, 12.2% were teased a few times a month, and 19.8% were teased at least once a week. Among very overweight boys (BMI 95th percentile), 27.9% reported being teased about their weight a few times a year, 10.8% were teased a few times a month, and 11.4% were teased at least once a week.


127 Prevalence of weight-teasing across ethnicity=race among overweight youth Prevalences of frequent weight-teasing ( few times a year), weight-teasing by peers (ever), and weight-teasing by family (ever) were examined across ethnicity=race among moderately and very overweight girls and boys (BMI 85th per-

centile). Among girls, statistically significant differences in weight-teasing were not found across ethnicity=race. Among boys, statistically significant differences were only found for weight-teasing by family members. Weight-teasing by family members was most frequently reported by Native American boys (39.3%) and Asian-American boys (35.3%), and least

Table 3 Numbers and percentages of adolescent girls and boys who are bothered by being teased about their weight by peers or family members across weight status Teased by peers Number teaseda

Number botheredb

Teased by family Percentage botheredc

Number teaseda

Number botheredb

Percentage botheredc

Girls Very underweight (n ¼ 95) Average weight (n ¼ 1267) Moderately overweight (n ¼ 406) Very overweight (n ¼ 250)

44 262 123 154

18 119 79 106 w2 ¼ 29.4 P < 0.001

40.9 45.4 64.2 68.8

22 290 136 116

12 119 75 75 w2 ¼ 20.9 P < 0.001

54.6 41.0 55.2 64.7

Boys Very underweight (n ¼ 116) Average weight (n ¼ 1300) Moderately overweight (n ¼ 297) Very overweight (n ¼ 333)

44 167 77 191

7 44 33 75 2 w ¼ 15.9 P < 0.001

15.9 26.4 42.9 39.3

15 136 48 111

1 24 20 43 2 w ¼ 21.2 P < 0.001

6.7 17.7 41.7 38.7

a

Number of youth reporting being teased by kids (or family). Number of youth who are teased who report that it bothers them ‘somewhat’ or ‘very much’. c Percentage of youth who are teased who report that it bothers them ‘somewhat’ or ‘very much’. b

Table 4 Numbers and percentages of overweight adolescent girls and boys (BMI 85th percentile) reporting disordered eating behaviors by perceived weight-teasing Unhealthy weight control

Girls Frequent weight teasing: Yes No Weight teasing by peers: Yes No Weight teasing by family: Yes No Boys Frequent weight teasing: Yes No Weight teasing by peers: Yes No Weight teasing by family: Yes No

Binge eating

Na

nb

%

w2 (P-value)

Na

nb

%

w2 (P-value)

225 422

179 285

79.6 67.5

10.3 (P < 0.001)

218 412

64 67

29.4 16.3

14.8 (P < 0.001)

284 367

221 246

77.8 67.0

9.2 (P < 0.002)

269 356

77 54

27.6 15.3

14.5 (P < 0.001)

254 396

207 259

81.5 65.4

19.7 (P < 0.001)

245 387

65 64

26.5 16.5

9.2 (P < 0.002)

231 394

142 166

61.5 42.1

21.8 (P < 0.001)

229 388

40 26

17.5 6.7

17.5 (P < 0.001)

279 354

161 144

59.9 40.7

22.4 (P < 0.001)

268 349

37 28

13.8 8.0

5.4 (P < 0.020)

161 464

103 202

64.0 43.5

20.0 (P < 0.001)

159 457

23 43

14.5 9.4

3.2 (P < 0.076)

a

Total number. Number reporting unhealthy weight control or binge eating behaviors.

b

International Journal of Obesity


128

frequently reported by white boys (20.9%; w2 ¼ 12.9, P ¼ 0.029).

Degree to which youths reported being bothered by weight-teasing Among girls who reported weight-teasing, statistically significant associations were found between weight status and the degree to which they reported being bothered by teasing (Table 3). Very overweight girls were the most bothered by teasing by peers and family members. A high percentage of underweight girls also reported being bothered by weight-teasing by family members. Among the boys who reported weight-teasing, statistically significant associations were also noted between weight status and the degree to which they were bothered by the teasing (Table 3). However, in contrast to the girls, few underweight boys reported that the teasing bothered them. It is noteworthy that high percentages of girls in all BMI categories reported that they were bothered by weight-teasing by peers and family members. Percentages of boys reporting being bothered by the teasing tended to be considerably lower than among the girls. For example, 38.4% of the very overweight boys reported that they were bothered by peer weight-teasing, in comparison to 64.5% of the very overweight girls.

Associations between weight-teasing and weight control=binge eating behaviors Significantly higher percentages of overweight girls and boys who were teased about their weight engaged in unhealthy weight control and binge eating behaviors, as compared to overweight girls and boys who were not teased about their weight (Table 4). Similar associations were found after adjusting for BMI, SES and school level (Table 5). Overweight youth who experienced weight-teasing were at significantly greater risk for engaging in unhealthy weight control and binge

eating behaviors than overweight youth who had not experienced weight-teasing. In both adjusted and unadjusted analyses, all associations were statistically significant except for the association between weight-teasing by family members and binge eating among the boys; this association was of marginal statistical significance. Although our primary interest was in examining associations between weight-teasing and weight control=binge eating behaviors among overweight youths associations were also examined within the total population (data not shown in tables). Similar patterns were found within the total population as were found among the overweight youth. Adolescents (overweight and non-overweight) who were teased about their weight were at significantly greater risk for engaging in unhealthy weight control and binge eating behaviors than youths who did not report being teased.

Discussion The findings clearly indicate that perceived weight-teasing by both peers and family members is common among adolescents. Gender differences in perceived weight-teasing are apparent: girls are teased more than boys, and girls report being bothered more by the teasing than boys. Gender differences in weight-teasing appear to be particularly large for non-overweight youths; non-overweight girls report higher levels of weight-teasing than non-overweight boys. The findings further demonstrate that weight-teasing is strongly associated with weight status; very overweight youth are at greatest risk for being teased about their weight, however underweight youth are also likely to be teased. As expected, overweight youth are more bothered by the weight-teasing than non-overweight youth; they may experience more frequent and severe teasing and=or may be more sensitive to it than their non-overweight peers. We are not aware of other large population-based studies of adolescents in which prevalences of weight-teasing have been examined across gender and weight status. However,

Table 5 Disordered eating behaviors among overweight adolescent girls and boys (BMI 85th percentile) by perceived weight teasing: odds ratios (OR) and 95% confidence intervals (CI)a,b Nc

OR

CI

Nc

OR

CI

Girls Frequent weight teasing Weight teasing by peers Weight teasing by family

625 629 627

1.93 1.73 2.28

(1.28, 2.94) (1.12, 2.58) (1.53, 3.44)

609 612 610

2.09 2.11 1.77

(1.38, 3.18) (1.37, 3.25) (1.77, 2.69)

Boys Frequent weight teasing Weight teasing by peers Weight teasing by family

604 604 604 604

1.86 2.11 2.11 1.86

(1.29, (1.47, (1.47, (1.24,

596 596 596 595

3.28 1.86 1.86 1.60

(1.86, (1.05, (1.05, (0.87,

a

2.69) 3.06) 3.06) 2.79)

5.93) 3.35) 3.35) 2.85)

Adjusted for BMI, socio-economic status, ethnicity and school level. Odds ratios are statistically significant (P < 0.05) when 1.0 is not included in the 95% confidence intervals; statistically significant odds ratios are in bold type. c Numbers included in calculation of specific odds ratios. b



129 our findings are in line with previous work focusing on stigmatization of overweight youth.22 Sobal and his colleagues22 found that overweight students, especially girls, were stigmatized regarding dating activities. Only 12% of the students had dated someone who was overweight, with girls (16%) more often dating overweight peers than boys did (8%). Adolescents, in particular boys, expressed low comfort levels in dating overweight peers, and comfort levels were lowest for dating a very overweight individual. Therefore, both Sobal’s22 study and our study suggest that weight-related stigmatization is more likely to affect girls than boys, and more likely to effect the heaviest youths. In the present study, differences in perceived weightteasing of overweight youth across ethnic groups were minimal. The lack of association between weight-teasing and ethnicity among overweight girls is noteworthy. In a small qualitative study that was conducted with 50 African-American and Caucasian overweight adolescent girls, weightrelated stigmatization experiences also did not differ greatly across ethnicity.12 However, numerous studies have found that restrictive dieting is less prevalent among African-American girls than white girls, suggesting a greater acceptance of different body sizes within African-American culture.23 – 26 The literature regarding ethnic differences in weight acceptance is not clear-cut; increasing similarities across different ethnic groups may be due to a diffusion of social norms across cultures via numerous mass media channels, increased opportunities for integration of persons from different backgrounds, and a tendency towards adopting the norms of the dominant culture within society. Findings from this study indicate that weight-teasing is prevalent among adolescents, in particular among those who deviate from the average range for weight status. The important question then becomes: does it matter? What are the potential implications of being teased about one’s weight as an adolescent, and in particular as an overweight adolescent? In the present study, high percentages of youth who were teased reported that they were bothered by it. Furthermore, we found strong associations between weight-teasing and disordered eating behaviors; youth who are teased about their weight are significantly more likely to engage in these behaviors. Among overweight youth, the use of unhealthy weight control and binge eating behaviors is of concern in that these behaviors may place youth at risk for further weight gain. Furthermore, the use of unhealthy weight control and binge eating behaviors may be early signs of more severe eating disturbances, of concern for both nonoverweight and overweight youths. That said, it is important to note that factors other than weight-teasing contribute to the onset of disordered eating. Furthermore, not all youth who experience weight-teasing engage in disordered eating. Findings from the present study regarding associations between weight-teasing and unhealthy weight control=binge eating behaviors are consistent with findings from previous studies using different populations and outcome measures. Brown and his colleagues15 compared a sample of adolescent

female binge-purgers (n ¼ 114) to a matched group of female controls (n ¼ 114) using data from a nationwide survey on body-image conducted in Psychology Today.27 They found that binge – purgers were more likely than controls to report that during childhood (before adolescence) peers made fun of them or rejected them because of their appearance. In a study of 385 young adolescent girls (ages 10 – 14), being teased or criticized about one’s weight=shape by family members was significantly correlated with body dissatisfaction, investment in thinness, weight management behavior and eating disturbance.28 Stormer and Thompson13 studied 162 female college students and found that a history of being teased about appearance contributed to explaining the variance in body dissatisfaction and eating disturbance, albeit the contribution was small after controlling for factors such as self-esteem, level of obesity, and internalization of sociocultural norms regarding beauty and thinness. In a study of a clinical sample of 115 adult women with binge eating disorders, a history of general appearance teasing was associated with current weight concerns and body dissatisfaction and both general appearance teasing and weight-specific teasing was associated with current psychological functioning.29 In a study of adult women (n ¼ 112) and men (n ¼ 34) seeking treatment for obesity, Myers and Rosen30 found that more frequent exposure to weight-related stigmatization (eg hurtful comments from others) was associated with greater psychological distress, poorer body image and lower selfesteem. This study had a number of strengths that contribute to the usefulness of the data. The nature of the study population (ie population-based sample), allowed for more generalization than is possible within clinical samples, samples drawn from fat-acceptance groups, or convenience samples recruited for the purpose of examining weight-related issues.12 The large size of the study population and its diversity allowed for comparisons of mistreatment across gender, weight and ethnicity. The collection of actual height and weight is another strength of this study, as most school-based studies of youth collect only self-reported measures. Another strength of the survey is its inclusion of various items assessing the frequency, source and effect of teasing as suggested by Thompson et al.21 However, in interpreting the findings, the study’s limitations need to be taken into account. The relatively small proportions of certain ethnic=racial groups (eg Native Americans) limit our ability to make conclusive statements regarding the prevalence of teasing across ethnicity=race. Furthermore, the self-reported nature of the data on weight-teasing needs to be taken into account. We were only able to assess perceived teasing. It is possible that the prevalence of weight-teasing is higher and goes unrecognized, or that the prevalence is lower but is magnified in the eyes of adolescents. Furthermore, it is possible that overweight youth are more sensitive to weight-specific mistreatment than non-overweight youth. The cross-sectional nature of the study also needs to be taken into account in International Journal of Obesity


130 drawing conclusions. We cannot assume that teasing is leading to the onset of unhealthy weight control and binge eating behaviors; it may be that weight-conscious youth who are more likely to engage in these behaviors are also more sensitive to weight-teasing. That said, the replication of this finding across different types of studies increases its credibility. In two longitudinal studies,16,17 teasing was found to be associated with body dissatisfaction while in several crosssectional studies associations were found between teasing and eating disturbances.13 – 15 Findings regarding the high prevalence of weight-teasing by peers and family members, the degree to which weightteasing bothers youths; and associations between weightteasing and disordered eating, indicate a need for appropriate interventions. Schools need to have clear-cut policies that do not allow for weight-teasing. Considerable strides have been made within educational and employment institutes regarding a lack of tolerance for gender and racial discrimination; similar steps are needed for weight-related discrimination and teasing. School-based educational interventions may be implemented with staff and students in which participants learn about the complex etiology of obesity, are made aware of their own attitudes and behaviors towards persons of different sizes, learn about the potential harmful effects of weight-teasing, and practice intervening when they hear others being teased. The high prevalence of weight-teasing by family members points to a need for parental or family interventions in which family members learn to recognize weight-related mistreatment and are made aware of its potential impact on their children. Discussions with parents may be part of routine health-care visits and relevant issues may be included within educational materials for parents of teenagers. It is imperative that public health, employment and educational systems strive to protect overweight children and adolescents from being unfairly mistreated and to promote their psychosocial and physical well-being.

Acknowledgements This study was supported by grant MCJ-270834 (D NeumarkSztainer, principal investigator) from the Maternal and Child Health Bureau (Title V, Social Security Act), Health Resources and Service Administration, US Department of Health and Human Services.

References 1 Centers for Disease Control and Prevention. Update: prevalence of overweight among children, adolescents, and adults — United States, 1988 – 1994. Morbid Mortal Weekly Rep 1997; 46: 199 – 202. 2 Neumark-Sztainer D, Harris T, Story M. Beliefs and attitudes about obesity among teachers and school health care providers working with adolescents. J Nutr Educ 1999; 31: 3 – 9. 3 Hill AJ, Silver EK. Fat, friendless and unhealthy: 9-year old children’s perception of body shape stereotypes. Int J Obes Relat Metab Disord 1995; 19: 423 – 430.


4 Phillips RG, Hill AJ. Fat, plain, but not friendless: self-esteem and peer acceptance of obese pre-adolescent girls. Int J Obes Relat Metab Disord 1998; 22: 287 – 293. 5 Larkin J, Pines H. No fat persons need apply. Sociol Work Occup 1979; 6: 312 – 327. 6 Lewis R, Cash T, Jacobi L, Bubb-Lewis C. Prejudice toward fat people: the development and validation of the antifat attitudes test. Obes Res 1997; 5: 297 – 307. 7 Hiller D. The salience of overweight in personality characterization. J Psychol 1981; 108: 233 – 240. 8 Gortmaker SL, Must A, Perrin JM, Sobol A, Dietz WH. Social and economic consequences of overweight in adolescence and young adulthood. New Engl J Med 1993; 329: 1008 – 1012. 9 Sonne-Holm S, Sorensen T. Prospective study of attainment of social class of severely obese subjects in relation to parental social class, intelligence, and education. Br Med J 1986; 292: 586 – 589. 10 Averett S, Korenman S. Black – white differences in social and economic consequences of obesity. Int J Obes Relat Metab Disord 1999; 23: 166 – 173. 11 Falkner N, French S, Jeffery R, Neumark-Sztainer D. Mistreatment due to weight prevalence and sources of perceived mistreatment in women and men. Obes Res 1999; 7: 572 – 576. 12 Neumark-Sztainer D, Story M, Faibisch L. Perceived stigmatization among overweight African American and Caucasian adolescent girls. J Adolesc Health 1998; 23: 264 – 270. 13 Stormer S, Thompson J. Explanations of body image disturbance: a test of maturational status, negative verbal commentary, social comparison, and sociocultural hypotheses. Int J Eat Disord 1996; 19: 193 – 202. 14 Fabian LJ, Thompson JK. Body image and eating disturbance in young females. Int J Eat Disord 1989; 8: 63 – 74. 15 Brown TA, Cash TF, Lewis RJ. Body-image disturbances in adolescent female binge-purgers: a brief report of the results of a national survey in the U.S.A. J Child Psychol Psychiatr 1989; 30: 605 – 613. 16 Cattarin J, Thompson J. A three year longitudinal study of body image and eating disturbance in adolescent females. Eating Disord J Prev Treatment 1994; 2: 114 – 125. 17 Thompson JK, Coovert MD, Richards KJ, Johnson S, Cattarin J. Development of body image, eating disturbance, and general psychological functioning in female adolescents: covariance structure modeling and longitudinal investigations. Int J Eat Disord 1995; 18: 221 – 236. 18 Grilo CM, Wilfley DE, Brownell KD, Rodin J. Teasing, body image, and self-esteem in a clinical sample of obese women. Addict Behav 1994; 19: 443 – 450. 19 Himes JH, Dietz WH. Guidelines for overweight in adolescent preventive services: recommendations from an expert committee. The Expert Committee on Clinical Guidelines for Overweight in Adolescent Preventive Services. Am J Clin Nutr 1994; 59: 307 – 316. 20 Centers for Disease Control and Prevention National Center for Health Statistics. CDC Growth Charts: United States. Advance Data; 2000. 21 Thompson JK, Cattarin J, Fowler B, Fisher E. The Perception of Teasing Scale (POTS): a revision and extension of the Physical Appearance Related Teasing Scale (PARTS). J Personal Assess 1995; 65: 146 – 157. 22 Sobal J, Nicolopoulos V, Lee J. Attitudes about overweight and dating among secondary students. Int J Obes Relat Metab Disord 1995; 19: 376 – 381. 23 Parker S, Nichter M, Nichter M, Vuckovic N, Sims C, Ritenbaugh C. Body image and weight concerns among African American and White adolescent females: differences that make a difference. Hum Org 1995; 54: 103 – 114. 24 Desmond SM, Price JH, Hallinan C, Smith D. Black and White adolescents’ perceptions of their weight. J School Health 1989; 59: 353 – 358.

Weight-teasing among adolescents D Neumark-Sztainer et al 25 Story M, French S, Resnick M, Blum R. Ethnic=racial and socioeconomic differences in dieting behaviors and body image perceptions in adolescents. Int J Eat Disord 1995; 18: 173 – 179. 26 Neumark-Sztainer D, Story M, Falkner NH, Beuhring T, Resnick MD. Sociodemographic and personal characteristics of adolescents engaged in weight loss and weight=muscle gain behaviors: Who is doing what? Prev Med 1999; 28: 40 – 50. 27 Cash TF, Winstead BA, Janda LH. The great American shape-up. Psychol Today 1986; April: 30 – 37.

28 Levine MP, Smolak L, Hayden H. The relation of sociocultural factors to eating attitudes and behaviors among middle-school girls. J Early Adolesc 1994; 14: 471 – 490. 29 Jackson T, Grilo CM, Masheb RM. Teasing history, onset of obesity, current eating disorder psychopathology, body dissatisfaction, and psychological functioning in binge eating disorder. Obes Res 2000; 8: 451 – 458. 30 Myers A, Rosen J. Obesity stigmatization and coping: relation to mental health symptoms, body image, and self-esteem. Int J Obes 1999; 23: 221 – 230.

131
