The relative stigmatization of eating disorders and obesity in males and females

Accepted Manuscript The Relative Stigmatization of Eating Disorders and Obesity in Males and Females Jessica M. Murakami, Jamal H. Essayli, Janet D. Latner PII:

S0195-6663(16)30060-5

DOI:

10.1016/j.appet.2016.02.027

Reference:

APPET 2879

To appear in:

Appetite

Received Date: 11 September 2015 Revised Date:

10 February 2016

Accepted Date: 11 February 2016

Please cite this article as: Murakami J.M., Essayli J.H. & Latner J.D., The Relative Stigmatization of Eating Disorders and Obesity in Males and Females, Appetite (2016), doi: 10.1016/j.appet.2016.02.027. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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Jessica M. Murakamia Jamal H. Essaylia Janet D. Latnera a

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The Relative Stigmatization of Eating Disorders and Obesity in Males and Females

University of Hawaiʻi at Manoa, Department of Psychology, 2530 Dole Street, Sakamaki C400 Honolulu, HI, 96822, USA

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[email protected] [email protected] [email protected]

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Correspondence: Jessica M. Murakami, 2530 Dole Street, Sakamaki C400, Honolulu, HI 96822, ([email protected])

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Abstract Objective: Anorexia nervosa (AN), bulimia nervosa (BN), binge-eating disorder (BED), and

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obesity are stigmatized conditions known to affect both men and women. However, little

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research has examined differences in stigmatization of individuals with these diagnoses or the

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impact of gender on stigmatization. Such perceptions may play an important role in

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understanding and reducing the stigma associated with weight and dysfunctional eating

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behaviors. This study investigated stigmatizing attitudes toward eating disorders and obesity in

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men and women.

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Method: Participants were university undergraduates (N = 318; 73.6% female; mean age =

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21.58 years, SD = 3.97) who were randomly assigned to read one vignette describing a male or

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female target diagnosed with AN, BN, BED, or obesity. Participants then completed measures of

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stigma and perceived psychopathology. Measures were analyzed using a 4 (target diagnosis) x 2

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(target gender) MANOVA and subsequent ANOVAs.

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Results: Measures of stigma and perceived psychopathology revealed significant main effects

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for diagnosis (p < .001), but not for target gender. There were no interactions between target

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diagnosis and gender. Although all diagnostic conditions were stigmatized, more biased

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attitudes and perceptions of impairment were associated with targets with AN and BN compared

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to targets with BED and obesity. Additionally, individuals with AN, BN, and BED were

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perceived as having significantly more psychological problems and impairment than individuals

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with obesity.

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Conclusion: Although individuals with eating disorders and obesity both face stigmatizing

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attitudes, bias against individuals with AN, BN, and BED may exceed stigma toward obesity in

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the absence of binge eating. Future research is necessary to address stigmatizing beliefs to

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reduce and prevent discrimination against both men and women with eating disorders and

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obesity.

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Keywords: Stigma; weight bias; eating disorders; obesity; gender

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Introduction Widespread stigma has been documented against individuals with weight- and eatingrelated disorders including obesity (Puhl & Heuer, 2009), anorexia nervosa (AN; Stewart, Keel

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& Schiavo, 2006), bulimia nervosa (BN; Roehrig & McLean, 2010), and binge-eating disorder

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(BED; Bannon, Hunter‐Reel, Wilson, & Karlin, 2009). This stigma is associated with a number

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of consequences, including social isolation, poor self-esteem, and psychological distress

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(Corrigan & Rusch, 2002; Holmes & River, 1998; Puhl & Heuer, 2009). Moreover, there may

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be a relationship between stigma and disordered eating, as research indicates that greater weight

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stigma increases the risk for disordered eating, and vice versa (Puhl & Suh, 2015). Given the

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profound effects of stigma, a more thorough understanding of stigmatizing attitudes toward

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individuals across the spectrum of weight- and eating-related conditions is warranted.

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Although research has demonstrated bias against individuals on both ends of the weight

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continuum (Swami, Pietschnig, Steiger, Tovee, & Voracek, 2010), few studies have compared

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stigmatizing attitudes across obesity and eating disorders (EDs). It is important to note that

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obesity is not an eating disorder. At the same time, research has demonstrated high rates of

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eating disordered symptoms in individuals with obesity (Darby et al., 2009), indicating an

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intimate relationship between weight status and eating disorders. Therefore, comparing the

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stigma associated with obesity and different eating disorders may improve our understanding of

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the roles of specific weight statuses (e.g., overweight, underweight) and behavioral eating

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disturbances (e.g., restriction, binge eating, compensatory behaviors) in stigma. The

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stigmatization of BED has received particularly little attention, despite the fact that many

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individuals with BED exhibit obesity coupled with eating disturbances (e.g., Zachrisson, Vedul-

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Kjelsas, Gotestam, & Mykletun, 2008; Kessler et al., 2013). Wingfield and colleagues (2011)

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compared stigma toward AN and BN, and found that women with BN were considered to be

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more responsible for their condition, more self-destructive, and having less self-control. Only

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one published study has examined stigmatizing attitudes across EDs and obesity (Ebneter &

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Latner, 2013); findings suggested that women with AN and BN are seen as similarly impaired

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and to blame for their condition, but more impaired and to blame for their disorder than women

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with BED or obesity. It may be the case that the general public conceptualizes BED as more

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similar to obesity than either AN or BN. Given the sparse comparative literature and mixed

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findings, more research using multiple validated measures of stigma is necessary to gain a better

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understanding of stigmatization across different EDs and obesity.

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Research exploring stigma toward obese men and women suggests that obese women

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experience significantly more stigmatization than obese men (Puhl, Andreyeva, & Brownell,

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2008). In contrast, very little is known about how stigmatizing attitudes toward men and women

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with eating disorders differ. Although men have historically been thought to comprise a very

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small minority of ED cases, more recent findings suggest that there may only be a small to

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moderate difference in the frequency of EDs in men and women (Striegel-Moore et al, 2009).

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Further, the clinical significance and level of impairment associated with EDs is similar between

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genders (Striegel, Bedrosian, Wang, & Schwartz, 2012). Despite these findings, significantly

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fewer males enter treatment for EDs compared to females (Striegel-Moore, Leslie, Petrill,

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Garvin, & Rosenheck, 2000), leading to speculation that men face alienation and stigma for

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having a “women’s disease” (Carlat, Camargo, & Herzog, 1997; Robinson, Mountford, &

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Sperlinger, 2013). To our knowledge, only two studies (Wingfield et al., 2011; Griffiths, Mond,

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Murray, & Youyz, 2014) have compared stigmatization of males and females with eating

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disorders, revealing few differences in stigmatization between genders. In their study of

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attitudes toward individuals with AN and BN, Wingfield and colleagues (2011) found only one

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difference between male and female targets in that women with these EDs were considered less

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likely to recover compared to men. Similarly, in an examination of gender differences in

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stigmatization of AN and muscle dysmorphia, Griffiths and colleagues (2014) found small

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effects indicating that women were more stigmatized than men on four of twenty-seven items

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assessing attitudes and beliefs toward vignette characters. Given these findings, further work is

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needed to examine potential differences in stigmatizing attitudes between men and women with

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AN, BN, and BED.

The present study compared stigmatizing attitudes across obesity and EDs. On the basis

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of past research (Ebneter & Latner, 2013), it was hypothesized that participants would endorse

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more general stigma against EDs compared to obesity, with those with EDs being seen as more

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psychologically impaired than those with obesity. Further, it was predicted that individuals with

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AN and BN would be perceived as more psychologically impaired than those with BED and

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obesity. This study also compared stigmatizing attitudes toward men and women with AN, BN,

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BED, and obesity to explore the potential effect of gender on stigma. Given the sparse literature

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in this area, no specific hypotheses related to gender were proposed. Materials and Methods

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Participants

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The study sample consisted of 318 university participants (73.6% female; mean age =

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21.58 years, SD = 3.97) recruited in April and May of 2014 from the University of Hawaiʻi at

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Mānoa (UHM), a public university located in Honolulu, Hawaiʻi with over 14,000

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undergraduates. Approximately 6% of UHM students are psychology majors. All participants

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were enrolled in psychology courses and offered course credit for participation. The ethnic

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background of this sample was 48.7% Asian, 25.8% Caucasian, 10.7% Pacific Islander, 3.5%

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Hispanic, 3.5% African or African American, and 6.6% other ethnicity. Their mean body mass

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index (BMI, kg/m2), based on self-reported height and weight, was 23.20 kg/m2 (SD = 5.09);

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9.7% were underweight (BMI <18.5 kg/m2), 63.8% were normal weight (18.5 kg/m2 ≤ BMI <

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25.0 kg/m2), 13.8% were overweight (25.0 kg/m2 ≤ BMI < 30.0 kg/m2), and 9.1% were obese

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(BMI ≥ 30.0 kg/m2). 6.9% of participants endorsed a past diagnosis of AN, BN, and/or BED.

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Procedures

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Data for this Institutional Review Board-approved study were collected using the online

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survey software, Surveymonkey.com. Participants took the survey using this software for free.

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At recruitment, participants were informed that the study was examining attitudes about different

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groups of people. Participants were randomly assigned to read one vignette describing a male or

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female target who met criteria for AN, BN, BED, or obesity, in a 2 (male vs. female) x 4 (AN vs.

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BN vs. BED vs. obesity) between-subjects design. The number of participants assigned to rate

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each of the eight vignettes ranged from 37 to 45. The six eating disorder vignettes (see

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Appendix A) were based on those used by Mond and colleagues (2004; 2006), Ebneter, Latner,

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and O’Brien (2011), and Ebneter and Latner (2013), and adapted to include gender. The obesity

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vignettes were based on those used by Murakami and Latner (2015) and modified to include the

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target’s gender and similar details to the eating disorder vignettes (e.g., the target’s overall diet).

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The behaviors and symptoms of each target in the eating disorder vignettes were described such

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that they met DSM-5 (American Psychiatric Association, 2013) criteria for AN, BN, or BED.

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To ensure target’s condition was unambiguous, all vignettes explicitly noted the target’s

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diagnosis by stating that the target had been recently diagnosed with the condition (e.g., “bulimia

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nervosa”).

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The AN vignettes described a male or female target who exhibits body dissatisfaction and a fear of becoming fat, subsequently becoming severely underweight through a combination of

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frequent exercise and caloric restriction. The BN vignettes described a male or female target

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who exhibits body dissatisfaction accompanied by recurrent episodes of binge eating and

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compensatory vomiting. The BED vignettes described a male or female target who experiences

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distress over recurrent episodes of binge eating that are associated with eating when not

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physically hungry, solitary eating, and subsequent guilt. As past literature indicates that differing

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etiological explanations may play a role in the stigmatization of eating disorders (Crisafulli,

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Thompson-Brenner, Frank, Eddy, &Herzog, 2010), no biological or sociocultural influences

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were described as contributing to the development of the target’s ED. Further, in order to avoid

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potentially confounding weight stigma with the description of these eating disorders and because

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the weight of individuals with eating disorders can widely vary, the weight of the targets with

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AN, BN, and BED was deliberately not quantified. Finally, to ensure that participants

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understood that patients met the medical definition of obesity, the obesity vignettes described a

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male or female target with a height and weight that equaled a BMI of 35.1, with no symptoms of

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BED. As research indicates that target weight history may influence stigma (Latner, Ebneter, &

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O’Brien, 2012), it was noted that the obese target’s weight has been stable for several years. In

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all four vignettes, the target was described as 21 years old, matching the mean age of respondents

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typically recruited from the University of Hawaiʻi system campuses. All vignettes were made

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uniform such that details unrelated to diagnosis and symptoms (e.g., names, occupation), and text

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length (105-114 words), were matched across conditions. Each participant read one vignette and

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then completed several measures that asked participants for their opinions about the specific

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target described.

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Measures Stigmatizing Attitudes. The 20-item Universal Measure of Bias (UMB; Latner, O’Brien,

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Durso, Brinkman, & MacDonald, 2008) assesses bias against different targets. This scale is

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comprised of 4 subscales: Negative Judgment, Distance, Attraction, and Equal Rights. Items are

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scored on a 7-point Likert Scale from 1 = strongly agree to 7 = strongly disagree; higher scores

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correspond to stronger bias against the target. Items were designed to retain identical item

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phrasing while allowing the insertion of a name or group into scale items (e.g., “People like

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[Name] are sloppy”). The UMB has demonstrated good convergent validity and internal

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consistency (Latner et al., 2008), and the measure has been used in previous research using

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vignettes describing individuals of different weights (e.g., Latner et al., 2012). Cronbach’s alpha

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for the overall scale in the present sample was 0.82, with subscale scores ranging from .73 to .87.

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In addition to the UMB, the 11-item Universal Stigma Scale (USS; Ebneter et al., 2011;

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Ebneter & Latner, 2013) was administered to assess participants’ stigmatizing attitudes toward

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vignette targets. Items on this self-report questionnaire are scored on a 5-point Likert Scale from

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1 = strongly agree to 5 = strongly disagree such that lower scores indicate more stigmatizing

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attitudes (e.g., “A problem like [Name]’s is a sign of personal weakness”). This composite

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measure yields two subscales—blame/personal responsibility and impairment/distrust—and has

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been employed in previous research using vignettes to describe individuals with eating disorders

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and obesity (Ebneter et al., 2011). In the present sample, Cronbach’s alphas for the

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blame/personal responsibility and impairment/distrust subscales were .73 to .84, respectively.

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Perceived Psychopathology. A brief scale assessed participants’ perceptions of the

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target’s psychological symptoms (e.g., “[Name] is probably depressed,” “[Name] should seek

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psychological treatment”). This four-item scale has been previously used to assess perceptions

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of psychopathology for vignette-based research on weight stigma (Latner, Puhl, Murakami, &

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O’Brien, 2014). Items were scored on a Likert scale from 1 = strongly agree to 4= strongly

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disagree, such that lower scores indicate greater participant perceptions of target

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psychopathology. In the present sample, Cronbach’s alpha was .85.

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Statistical Analyses

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Initial one-way univariate analyses of variance (ANOVAs) were run between groups on

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demographic variables to confirm adequate sample randomization. No differences were found

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between randomized experimental groups for BMI, reported eating disorder history, ethnicity,

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gender, or age of participants. Mean scores were then computed for the UMB subscales, total

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UMB, the USS subscales, and perceived psychopathology.

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Dummy variables were assigned to each vignette condition using a 4 × 2 classification;

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independent variables were target condition (AN vs. BN vs. BED vs. obesity) and target gender

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(male vs. female). Subsequently, a two-way multivariate analysis of variance (MANOVA) was

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conducted to compare variables across target condition and target gender. The MANOVA

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included the following dependent variables: UMB Negative Judgment, UMB Distance, UMB

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Attraction, UMB Equal Rights, UMB Total, USS blame/responsibility, USS impairment/distrust,

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and Perceived Psychopathology.1 Subsequent two-way ANOVAs were then conducted for each

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variable. The alpha level was set at .05 for all analyses. Effect sizes were calculated using

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Additional analyses including participant BMI, participant’s history of eating pathology, and participant gender as covariates were also conducted, but yielded no significant difference in the overall pattern of results. 10

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partial eta squared and interpreted using Cohen's (1988) guidelines for small (η2p = .01), medium

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(η2p = .06), and large effect sizes (η2p = .14).

Results Two-way MANOVA revealed a significant multivariate main effect for target diagnosis

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Wilks’ λ = .548, F(21, 709) = 7.88, p < .001, η2 p = .181, but not target gender, Wilks’ λ = .954,

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F(7, 247) = 1.68, p = .112, η2 = .046. There were no multivariate interactions between target

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diagnosis and target gender, Wilks’ λ = .949, F(21, 709) = 0.62, p = .904, η2 p = .017). Table 1

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shows the means, standard deviations, pairwise comparisons, and Cohen’s d effect sizes for both

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target genders across diagnostic conditions based on results of a follow up two-way ANOVA for

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the entire sample.

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3.16 (0.13)ab 3.67 (0.12)ab 4.82 (0.15)a 2.81 (0.16) 3.62 (0.69)a

3.55 (0.13)a 3.74 (0.12)a 5.09 (0.14)a 2.55 (0.16) 3.76 (0.78)a

2.96 (0.15)b 3.32 (0.15)b 4.23 (0.17)b 2.58 (0.19) 3.23 (0.63)b

2.90 (0.14)b 2.80 (0.13)c 4.19 (0.15)b 2.75 (0.16) 3.03 (0.89)b

.026 .040 .036 .010 .044

3.61 (0.09)a 3.45 (0.09)a 2.01 (0.06)a

3.52 (0.09)ab 3.49 (0.09)a 1.90 (0.06)a

3.41 (0.10)ab 3.73 (0.11)b 2.12 (0.07)a

3.17 (0.09)b 3.96 (0.10)c 2.81 (0.06)b

.026 .030 .065

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Universal Measure of Bias* Negative Judgment Distance Attraction Equal Rights Total Universal Stigma Scale** Blame/Personal Responsibility Impairment/Distrust Perceived Psychopathology**

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Table 1. Means and standard deviations of Universal Measure of Bias subscales, Universal Stigma Scale subscales, Perceived Psychology scale, and pairwise comparisons of stigmatizing attitudes across target diagnostic conditions AN BN BED Obesity Cohen’s Mean (SD) Mean (SD) Mean (SD) Mean (SD) d (n = 82) (n = 84) (n = 78) (n = 74)

* Higher scores indicate greater bias **Lower scores indicate greater blame, impairment, or perceived psychopathology Means with different superscripts differ significantly from each other (e.g., Negative Judgment for AN was not significantly different from BN, BED, or obesity, but BN significantly differed from BED and obesity). 216 217 218

Significant effects for the vignette target’s diagnostic condition were observed on the UMB Negative Judgment subscale, F(3, 253) = 6.42, p < .001, η2 p = .071, the UMB Distance

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subscale, F(3, 253) = 15.07, p < .001, η2 p = .152, the UMB Attraction subscale, F(3, 253) =

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14.28, p < .001, η2 p = .145, and the overall UMB scale, F(3, 253) = 12.63, p < .001, η2p = .130.

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No differences between diagnostic conditions were observed on the UMB Equal Rights

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Subscale, F(3, 253) = 0.80, p = .491, η2p =.009. Post hoc tests using the Bonferroni’s correction

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revealed that, for overall stigma, targets with BED or obesity were less stigmatized than targets

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with AN or BN. Similarly, compared to targets diagnosed with BED or obesity, targets

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diagnosed with AN and BN were considered less attractive. Although targets with BN were

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significantly more negatively judged and elicited more discomfort with proximity compared to

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targets with BED, on these two dimensions, targets with BN did not differ from targets with AN.

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Finally, statistically significant differences emerged such that BN was more stigmatized than

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obesity on dimensions of negative judgment, proximity discomfort, and attraction.

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Significant effects for vignette condition were also observed on the USS blame/personal

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responsibility subscale, F(3, 253) = 3.88, p = .010, η2 p = .044, and the USS impairment/distrust

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subscale, F(3, 253) = 10.22, p < .001, η2 p = .108. Post hoc tests revealed that targets diagnosed

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with obesity were blamed significantly more for their condition compared to targets with AN.

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No significant differences emerged between obesity and BN or BED on the USS blame/personal

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responsibility scale. Further, targets with AN, BN, and BED were rated as significantly more

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impaired than individuals with obesity, and targets with AN and BN were rated as more impaired

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than individuals with BED.

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Finally, a significant effect emerged on the perceived psychopathology scale, F(3, 253) =

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41.46, p < .001, η2 p = .330, such that individuals with eating disorders were perceived as

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significantly more disturbed than individuals with obesity.

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Discussion

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The present study compared stigmatizing attitudes toward and perceived psychopathology associated with AN, BN, BED, and obesity in male and female targets. To

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increase confidence in our findings, three different measures of stigma were administered and

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compared. Results converged on all three measures and suggest that stigmatizing attitudes and

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perceptions of psychopathology vary across obesity and ED diagnosis, typically yielding

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medium to large effect sizes.

Consistent with prior findings (Ebneter & Latner, 2013) and our hypothesis, post-hoc

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tests indicated that targets with AN and BN were more stigmatized than non-ED obese targets on

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most measures of stigma. Further, statistically significant differences emerged between BN and

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obesity targets on most measures of stigma, including negative judgment, proximity discomfort,

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low attraction, impairment, and perceived psychopathology. One notable exception emerged on

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the blame subscale of the USS: obese targets were blamed more for their condition than targets

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with AN. These findings might indicate that the perception of disturbed eating behaviors (e.g.,

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binge eating, compensatory behaviors, and dietary restraint) is a potent source of stigma, perhaps

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even more so than perceived personal responsibility.

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Although AN was more stigmatized than obesity, they were blamed less for their

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condition than obese individuals. This finding appears to contradict controllability theory, which

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suggests that weight stigma is rooted in blame and can be thought of as the last socially

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acceptable form of prejudice (Crandall, 1994). This finding also appears to conflict with

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attribution theory (Weiner, Perry, & Magnusson, 1988), which posits that negative reactions are

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the result of one’s perceived responsibility for their condition. Nevertheless, the negative

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attitudes toward EDs observed in the present study may also be related to body weight. For

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example, respondents might associate dysfunctional eating with weight fluctuations, weight gain,

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or a history of being overweight. Research has demonstrated that a history of obesity, even

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among presently normal weight targets, can be as stigmatized as current obese status (Latner et

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al., 2012). It is also possible that dysfunctional eating and compensatory behaviors (e.g.,

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vomiting) might elicit disgust reactions, as disgust is associated with weight-related stigma

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(Lieberman, Tybur, & Latner, 2012).

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Also consistent with our hypothesis and converging with prior research (Ebneter &

Latner, 2013) was the finding that targets with BED were seen as more attractive, less impaired,

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and less stigmatized overall compared to targets with AN or BN. However, targets with BED

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did not differ from targets with AN on dimensions of negative judgment and distance.

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Nevertheless, targets with BED were significantly more stigmatized than targets with obesity on

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measures of proximal discomfort, impairment, and perceived psychopathology. These results

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suggest that although EDs are significantly more stigmatized than obesity, BED is nonetheless

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viewed as a less severe condition than AN or BN. Alternatively, participants may have assumed

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that the BED target was psychologically impaired because he or she was given a label of a

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mental illness in the vignette description, rather than because of the nature of the BED symptoms

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described. Additional research is necessary to determine whether the label of “binge-eating

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disorder” contributes to stigma. Similarly, there were no significant differences in perceptions of

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psychopathology between targets with AN, BN, and BED. Perceptions of mental illness and/or

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the use of diagnostic labels in all three ED conditions may have led to their increased stigma, as

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more global negative attitudes are associated with having any type of mental illness or disability

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(Crisp, Gelder, Rix, Meltzer, & Rowlands, 2000; Corrigan, 2014). It is also worth exploring

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whether the egosyntonic nature of eating disorders may render them more stigmatizing than

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obesity (Crisp et al., 2000).

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Additionally, stigmatization when a target’s diagnosis is provided may differ from stigmatization in the absence of this knowledge. In real world circumstances, the appearance of

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the target may be more likely to elicit stigmatization. This may result in greater stigmatization of

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individuals with visible conditions (such as obesity and severe AN resulting in emaciation)

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relative to less apparent pathology (such as BN, BED, and less severe AN which may present as

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normal weight or overweight).

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This study found no effect for target gender in the stigmatization of AN, BN, BED, or

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obesity. Although null findings must be interpreted with caution, the absence of differences in

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bias against male and female targets with obesity is surprising as past research has indicated that

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obese women report experiencing significantly more stigmatization compared to obese men

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(Puhl et al., 2008). Nevertheless, it is noteworthy that the eating disorder results supplement the

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mixed findings of the two existing studies that investigated the relationship between gender and

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stigmatization of eating disorders (Wingfield et al., 2011; Griffiths et al., 2014). In both studies,

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few differences were observed in the stigmatization of men and women with eating disorders.

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For example, no differences emerged in participant ratings of male and female targets with AN

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or BN on dimensions of likeability, responsibility for their ED, sexual orientation, self-control,

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or self-destructiveness (Wingfield et al., 2011). Further, an investigation of stigmatizing

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attitudes against male and female targets with AN and muscle dysmorphia, yielded no gender

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differences on 23 of 27 items assessing negative attitudes (Griffiths et al., 2014). In contrast to

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the present study, this past research relied primarily on single-items rather than scaled scores

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from validated measures of stigma. Taken together, the past and current findings may suggest

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that men and women with eating disorders face similar levels of stigma. If this is indeed the

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case, the low number of men who seek treatment for an eating disorder (Striegel-Moore et al.,

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2000) may be related to barriers other than stigma from others. Barriers affecting men may

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include poorer knowledge about eating disorders, reduced screening and referrals for disordered

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eating, less access to eating disorder treatment, and/or self-stigmatization and shame related to

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traditional gender roles and/or their condition. Nevertheless, given the limited research in this

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area, further work is needed to clarify whether or not differences exist in the expression and

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interpretation of stigma against males and females with eating disorders.

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The present study had several strengths and limitations. This study benefited from the

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inclusion and interpretation of scaled scores from validated measures of stigma. Additionally,

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this study utilized a large sample with considerable ethnic diversity. As such, the attitudes of

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previously understudied populations, including Asians and Pacific Islanders, were assessed.

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Nevertheless, although the study’s ethnically diverse sample is consistent with the demographics

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of Honolulu, the ethnic distribution of the sample differs from other parts of the United States

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and may not generalize to populations from other geographical regions. Further, this study’s

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sample consisted of predominantly female students recruited from psychology courses at a

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university. As such, the lack of participant gender differences could possibly reflect the sample

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composition of this study rather than the absence of true differences between male and female

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participants. Similarly, participants had attained higher levels of education compared to the

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general population. Given the sample characteristics, the generalizability of this study’s findings

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is limited. Future studies should strive to recruit more men as well as a wider range of age

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groups, education levels, and ethnic groups. Further, although participants’ past diagnoses of an

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eating disorder were assessed, no measure of current eating disordered behavior was

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administered. Therefore, it is difficult to determine the extent to which participants' current

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eating disorder psychopathology and experiences of stigmatization may have influenced their

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responses. Additionally, the present study used explicitly-worded questions on the self-report

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measures of stigma, which may have introduced social desirability as a potential confound;

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future studies might include implicit measures of stigma. Finally, while the perceived

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psychopathology scale has been used in previous research, additional research is recommended

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to establish the validity of this scale.

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Conclusion

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stigmatization of targets at both ends of the weight spectrum. Further, these results suggest that

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although individuals with eating disorders and obesity both face stigmatizing attitudes, bias

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against individuals with AN, BN, and BED may exceed stigma toward obesity in the absence of

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binge eating. Additionally, this study highlights the stigma associated with eating disorders and

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obesity. Therefore, it is necessary for clinicians to work with patients suffering from eating

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disorders and obesity to address and manage stigmatization as a result of their diagnoses. As

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conditions associated with shame and guilt (e.g. Frank, 1991; Burney & Irwin, 2000; Jambekar,

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Masheb, & Grilo, 2003), anti-stigma interventions may also aim to erode stigma as a barrier to

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treatment seeking by individuals with these conditions. These findings underscore the

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importance of a more detailed understanding of the different aspects of stigma related to these

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conditions.

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This study adds to the existing body of literature that documents the presence of

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Given the prevalence of obesity (Flegal, Carroll, Kit, & Ogden, 2012), eating disorders

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Hudson, Hiripi, Pope, & Kessler, 2007), and weight stigmatization (Puhl & Heuer, 2009), further

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research should continue to address these important questions regarding the nature and extent of

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stigma associated with different eating- and weight-related conditions in men and women.

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Additional research could also examine bias directed toward other variants of eating disorders

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(e.g., AN purging subtype, targets of different weights), as well as toward isolated eating

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behaviors (e.g., compensatory vomiting), to help identify the specific variants and symptoms of

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eating disorders that might be most harshly stigmatized. Such research is necessary for the

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development of effective stigma-reduction interventions to improve the treatment and quality of

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life for individuals with these behaviors and conditions.

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Appendix A

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Anorexia Nervosa:

476 477 478 479 480 481 482 483 484 485 486 487 488

[Amanda/Matthew] is a 21-year-old second-year university student. Upon starting college, [Amanda/Matthew] was unhappy with the size and shape of [her/his] body so (s)he joined a fitness program at the gym and started running daily. Through this effort, (s)he gradually began to lose weight. At the same time [Amanda/Matthew] started to “diet”, avoiding all fatty foods, not eating between meals, and trying to eat set portions of “healthy foods” each day. On some days (s)he doesn’t eat anything at all. Through this combination of dieting and exercise, [Amanda/Matthew] has been able to further reduce [her/his] weight to the point that (s)he is now severely underweight. Despite [her/his] increasingly thin and gaunt appearance, [Amanda/Matthew] denies that (s)he is underweight. (S)he is terrified of becoming “fat” and refuses to make any effort to put weight back on. As a result, the relationship between [Amanda/Matthew] and [her/his] friends and parents has become strained and [her/his] grades at school have started to slip. Recently, [Amanda/Matthew] has been diagnosed with Anorexia Nervosa.

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Bulimia Nervosa:

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[Amanda/Matthew] is a 21-year-old second-year university student. Upon starting college, [Amanda/Matthew] was unhappy with the size and shape of [her/his] body so (s)he joined a fitness program at the gym and started running regularly. Through these efforts, (s)he gradually began to lose weight. [Amanda/Matthew] then started to “diet”, avoiding all fatty foods, not eating between meals, and trying to eat set portions of “healthy foods” each day. However, [Amanda/Matthew] has found it difficult to control [her/his] eating. While able to restrict [her/his] dietary intake during the day, later on (s)he is often unable to stop eating. (s)he may binge eat, for example, on an apple, two slices of cheesecake, a bag of cookies, a jam sandwich and three glasses of milk, all in one sitting. To prevent gaining weight, [Amanda/Matthew] makes [her/himself] vomit after these episodes of binge eating. As a result of [her/his] disorder, the relationship between [Amanda/Matthew] and [her/his] friends and parents has become strained and [her/his] grades at school have started to slip. Recently, [Amanda/Matthew] has been diagnosed with Bulimia Nervosa.

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Binge Eating Disorder:

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[Amanda/Matthew] is a 21-year-old second-year university student. Over the years [Amanda/Matthew], has been unhappy with the size and shape of [her/his] body so (s)he has tried a number of diet and healthy eating plans. [Amanda/Matthew] lives by himself and often feels lonely. To counteract these feelings, [Amanda/Matthew] eats foods that are high in calories such as chocolate and cheesecake. [Amanda/Matthew]’s overall diet is generally regular, with three meals a day that consist of a wide variety of foods. When [Amanda/Matthew] gets home from school, (s)he often goes to the fridge for a small snack; however, [Amanda/Matthew] finds that after eating the snack (s)he is unable to stop eating and continues to eat a large amount of food. (S)he may binge eat, for example, on an apple, two slices of cheesecake, a bag of cookies, a jam sandwich, and three glasses of milk, all in one sitting. [Amanda/Matthew] feels sad and guilty after these binge eating episodes and hates the shape of [her/his] body. [Amanda/Matthew] has never told anyone about how (s)he feels or the way (s)he loses control of [her/his] eating.

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Recently, [Amanda/Matthew] has been diagnosed with Binge Eating Disorder.

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Obesity:

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[Amanda/Matthew] is a 21-year-old second-year university student. (S)he reached [her/his] current height of [5 feet and 4 inches (1.62m)/5 feet and 10 inches (1.78m) at about 16 years of age and since then (s)he has always weighed around [205 pounds(93 kg)/245 pounds (111kg)]. [Amanda/Matthew]’s adult weight has remained stable over the past several years. [Amanda/Matthew]’s overall diet is generally regular, with three meals a day that consist of a wide variety of foods and snacks. [Amanda/Matthew] sometimes eats foods that are high in calories such as chocolate and cheesecake. Recently, [Amanda/Matthew]’s doctor has told [her/him] that, based on [her/his] height and weight, (s)he is Obese.

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