pediatrics
January 2013, VOLUME131 /ISSUE 1

Weight-Based Victimization: Bullying Experiences of Weight Loss Treatment–Seeking Youth

  1. Rebecca M. Puhl, PhD,
  2. Jamie Lee Peterson, MA, and
  3. Joerg Luedicke, MS
  1. Rudd Center for Food Policy and Obesity, Yale University, New Haven, Connecticut

Abstract

OBJECTIVE: Few studies have comprehensively examined weight-based victimization (WBV) in youth, despite its serious consequences for their psychosocial and physical health. Given that obese and treatment-seeking youth may be highly vulnerable to WBV and its negative consequences, the current study provides a comprehensive assessment of WBV in a weight loss treatment–seeking sample.

METHODS: Adolescents (aged 14–18 years; N = 361) enrolled in 2 national weight loss camps were surveyed. An in-depth assessment of WBV was conducted by using an online survey, in which participants indicated the duration, typical locations, frequent perpetrators, and forms of WBV they had experienced.

RESULTS: Findings indicate that 64% of the study participants reported WBV at school, and the risk of WBV increased with body weight. Most participants reported WBV enduring for 1 year (78%), and 36% were teased/bullied for 5 years. Peers (92%) and friends (70%) were the most commonly reported perpetrators, followed by adult perpetrators, including physical education teachers/sport coaches (42%), parents (37%), and teachers (27%). WBV was most frequently reported in the form of verbal teasing (75%–88%), relational victimization (74%–82%), cyberbullying (59%–61%), and physical aggression (33%–61%). WBV was commonly experienced in multiple locations at school.

CONCLUSIONS: WBV is a prevalent experience for weight loss treatment–seeking youth, even when they are no longer overweight. Given the frequent reports of WBV from adult perpetrators in addition to peers, treatment providers and school personnel can play an important role in identifying and supporting youth who may be at risk for pervasive teasing and bullying.

KEY WORDS
  • adolescents
  • obesity
  • teasing
  • weight bias
  • weight stigma
  • Abbreviations:
    PE
    physical education
    WBV
    weight-based victimization
  • What’s Known on This Subject:

    Studies have linked bullying with BMI, with overweight and obese youth vulnerable to bullying and its negative psychological and health consequences. However, there has been little comprehensive assessment of weight-based victimization, especially in weight loss treatment–seeking samples of youth.

    What This Study Adds:

    WBV is prevalent in treatment-seeking youth, who report victimization from peers (92%), friends (70%), parents (37%), and teachers (27%). Providers should discuss WBV in their assessment and treatment of pediatric patients who are overweight or obese.

    According to recent research, body weight is one of the most common reasons that adolescents are bullied at school, with rates higher than bullying due to race, religion, or disability, and comparable to youth who are bullied because of their sexual orientation.1 Alarmingly, 84% of adolescents in this study observed overweight students being teased at school.1 This finding is especially concerning given that the number of overweight and obese youth has increased substantially over recent decades,2 and in 2010, 32% of US 2- to 19-year-olds were classified as clinically overweight or obese.3 Although previous research413 and recent reviews14,15 have linked child BMI with involvement in victimization, there has been limited comprehensive assessment of teasing/bullying specifically about weight (ie, weight-based victimization [WBV]), especially in weight loss treatment–seeking samples of overweight youth.

    WBV poses a range of negative health consequences for youth who are targeted. Specifically, WBV can increase the risk for behaviors that may contribute to weight gain (eg, increased caloric consumption, binge eating, unhealthy weight control behaviors, increased preference for sedentary activities, skipping physical education [PE] class).1618 WBV can also have negative psychological outcomes (eg, low self-esteem, depressive symptoms, suicidal thoughts and behaviors)19 and academic consequences (eg, skipping school, poorer academic performance).18,20 Weight-based teasing/bullying may also contribute to social isolation or low peer acceptance of overweight youth.2123 Thus, WBV can hinder social, emotional, and academic development of youth, as well as exacerbate adverse health behaviors already associated with obesity.

    According to an American Academy of Pediatrics policy statement, health providers should advocate for “bullying awareness by teachers, educational administrators, parents, and children.”24 In light of the pervasiveness and consequences of victimization toward overweight youth, health care providers have an important role to play in identifying youth who are at risk and offering support and resources to help these youth effectively cope with WBV and its consequences. It is also important to protect children and adolescents from victimization as part of efforts to address obesity in youth, which can otherwise erode intervention and treatment intended to improve their healthy lifestyle behaviors.

    However, the ability of providers to effectively help youth who are most vulnerable can be hindered in the absence of an accurate knowledge of the specific challenges these youth face, such as the frequency, types, and perpetrators of WBV they experience and other patient characteristics that may increase the risk of WBV. This knowledge is particularly important to obtain in treatment-seeking youth, given that obese youth may be more likely to be teased or bullied,25 and heavier youth report that teasing is more harmful, upsetting, and frequent than their nonoverweight peers.17 In addition, the relation between teasing and psychological maladjustment is higher for obese youth,26 and negative consequences resulting from victimization may be more pronounced in treatment-seeking youth.27,28

    Previous studies examining treatment-seeking samples of overweight youth (ie, those participating in weight loss programs) have used only a few survey items to assess the presence/history of weight-related teasing29 or relied on brief scales such as the Perception of Teasing Scale30 as well as other scales.3135 The Perception of Teasing Scale includes 6 items to assess general experiences of weight-based teasing but provides no examination of the frequency or different forms of WBV experienced (verbal, relational, cyberbullying, or physical aggression) or perpetrators (friends or family members). A more comprehensive assessment of weight-specific victimization is necessary to obtain an accurate knowledge of the specific challenges facing these youth and has important practical implications for identifying factors that can be addressed in interventions to reduce WBV and to increase awareness of this form of bullying among treatment providers, school personnel, and program staff.

    To address this research gap, an in-depth self-report measure was developed to assess WBV in youth, including its multiple forms, common settings where WBV occurs, frequent perpetrators of WBV, and the frequency of these experiences. Originally surveyed in a large community sample of high school students,1,18 this measure has not yet been tested in a weight loss treatment–seeking sample. Given the increased risk of victimization of these individuals and the resulting negative consequences, the current study aimed to assess WBV in a treatment-seeking sample. To our knowledge, this study provides the first comprehensive examination of WBV in a treatment-seeking sample of adolescents.

    Methods

    Participants

    The target sample was adolescents (aged 14–18 years) enrolled in 1 of 2 youth weight loss programs: Wellspring Camps36 or Camp Shane.37 Programs were selected for their large enrollment, numerous program facilities, and participation across the United States. Each program e-mailed a recruitment flyer to parents of enrolled youth during the spring of 2011. Participants provided written informed consent, and if aged <18 years, passive parental consent was also required. Gift cards were offered as incentives. The study was approved by the directors of each program and by the authors’ university institutional review board.

    Data were collected online via self-report surveys advertised to currently enrolled campers. For Camp Shane, 1025 e-mails were received and viewed by potential participants, and 400 campers from Wellspring Academies received e-mails about the survey. Of participants who began the survey (N = 550), a portion of participants did not provide consent (n = 38) or did not finish (n = 123), resulting in a 70.7% completion rate and an effective response rate of 27.3%. This response rate approximates previous Web-based assessments of youth bullying38 and is within the expected range for well-conducted online surveys without follow-up contact.39 Exclusions were made for participants who were aged <14 years or >18 years (n = 7), underweight (n = 15), or non–native English speakers (n = 6). Participants from Camp Shane (76%) and Wellspring Academies (23%) were represented in the final sample (N = 361). Reported experiences of WBV were not significantly different according to program, and samples were thus pooled. Several participant demographic characteristics differed across programs. Therefore, BMI, gender, age, race, and a binary variable specifying camp program were included as predictor variables in regression analyses.

    Measures

    Demographic Information

    Participants reported their age, gender, race/ethnicity, and academic performance. Self-reported height and weight were collected to calculate BMI. BMI percentiles were calculated with respect to age and gender based on the Centers for Disease Control and Prevention growth curves,40 then classified according to weight categories (eg, healthy weight, overweight, obese).41 Given that BMI may differ for youth by gender but several participants did not report gender (n = 57), BMI was calculated for participants with missing gender information as both a male and a female. If participant weight category changed based on participant gender classification, BMI category was not recorded (n = 8).

    Experiences of WBV

    The nature and extent of WBV were assessed with a questionnaire adapted from Puhl et al.1,18 Participants were provided with a detailed definition of bullying, followed by the questions: “Have you ever been teased or bullied because of your weight at school?” (1 = yes, 2 = no), “How often have you been teased or bullied because of your weight at school during the last year?” (1 = never to 5 = very often), and “How long have you been teased or bullied because of your weight at school?” (1 = <1 month to 6 = ≥5 years).

    Survey questions then assessed teasing due to other factors (eg, race, religion, sexuality) and frequent perpetrators of WBV (“peer,” “friend,” “teacher,” “Physical Education [PE] teacher/sport coach,” “parent,” or “I do not know who the person is”). To assess specific forms of WBV experienced by adolescents, participants were asked how often during the past year (“never” to “very often”) they had experienced different types of victimization at school, specifically attributable to their body weight. Items assessed types of verbal teasing, physical aggression, relational victimization, and cyberbullying. This measure showed very good reliability (α = .94). Participants were also asked to report how often (“never” to “very often”) they had experienced WBV in specific locations and via technology (ie, on the computer or cell phone) at school.

    Finally, preliminary evidence from research with weight loss treatment–seeking youth documented a negative relation between maternal BMI and child self-esteem and adaptive skills.42 Thus, perceived parental weight status was also assessed: “Which of the following best describes your biological mother’s/father’s weight?” (“very underweight,” “underweight,” “just about right,” “overweight,” “very overweight,” and “I don’t know”).43 Due to sparse cell coverage, “overweight”/“very overweight” and “very underweight”/”underweight”/“just about right” were collapsed, resulting in binary variables for the mother and the father. These 2 binary variables were then combined into 1 variable with 3 categories: 0, 1, or both parents overweight/very overweight.

    Statistical Analysis

    The data were analyzed by using descriptive techniques to document experiences of WBV. In addition, regression models were used to estimate effects of individual characteristics on 2 of the study’s main outcome measures (ie, risk and frequency of WBV). Linear regression models (ordinary least squares) were used to predict frequency of WBV, both for overall and type-specific frequency, and a logistic regression model was used to predict the probability of ever experiencing WBV. Predictors were the same in all models and included adolescent and parent weight status, as well as sociodemographic characteristics such as age, gender, race/ethnicity, and grades. A binary variable indicating camp membership was included as a control variable. In a separate analysis, a cubic spline logistic regression model (without additional covariates) was used to explore the nonlinear effect of BMI on WBV risk. To avoid selection bias in models in which gender was included, missing gender data were imputed by using multiple imputation (M = 20).44 Analyses were conducted by using Stata version 11.2 (Stata Corp, College Station, TX).

    Results

    Participant Characteristics

    Of 361 participants, 40% were female and 44% were male (16% not reported). The mean ± SD age was 15.79 ± 1.28 years. Participants were currently in grades 7 or 8 (12%), 9 (27%), 10 (23%), 11 (17%), or 12 (21%). Most participants self-reported as white (71%), with the remaining 18% black/African American, 6% Latin/Hispanic, 2% Asian/Pacific Islander, and 3% other. Students reported receiving grades of mostly A’s (38%) and mostly B’s (40%), followed by mostly C’s (19%), mostly D’s (3%), and mostly F’s (0%). Thirty-four percent of respondents were healthy weight, 24% were overweight, and 40% were obese. Compared with recent US estimates, this sample contained more overweight youth and >2 times the current rate of youth obesity.3 It was unexpected that 34% of the sample reported having a BMI within the healthy weight range. However, program administrators confirmed that a portion of enrollees had experienced significant weight loss and returned to camp for support with weight loss maintenance.

    WBV

    Descriptive Findings

    Most participants reported experiencing WBV (64%). Results presented here pertain exclusively to participants who reported experiencing WBV, unless otherwise noted.

    Frequency and Duration

    Most youth (71%) reported experiencing WBV at least “sometimes” at school in the last year (Table 1). Adolescents also reported a long history of WBV; nearly 4 of 5 participants reported WBV lasting >1 year, and more than one-third had experienced WBV for ≥5 years. Only 10% of youth reported recent initiation of WBV within the past 6 months.

    TABLE 1

    Reported Reasons for Being Bullied or Teased at School

    Perpetrators

    More than 90% of participants reported that their peers had been perpetrators of WBV followed by 70% who reported their friends teased/bullied them (Table 2). Male (89%) and female (86%) peers were reported as perpetrators, with friends reported less often (males: 69%, females: 64%). Individuals whose identities were unknown were also commonly reported as perpetrators (55%), followed by a sizeable percentage of participants who reported WBV from adults, including PE teachers/sport coaches (42%), parents (37%), and teachers (27%).

    TABLE 2

    Adolescents’ Reports of Common Perpetrators of Weight-Based Bullying and Teasing During the Last Year

    Types of Victimization

    Verbal victimization was the most commonly reported form of WBV at school (75%–88%), followed by relational victimization (74%–82%) (Table 3). More than one-half of participants reported weight-based cyberbullying; namely, 61% had experienced mean or embarrassing posts online, and 59% were sent mean texts, e-mails, or instant messages. Physical victimization was reported least often, yet was still prevalent (33%–61%).

    TABLE 3

    Adolescents’ Reports of Different Forms of Weight-Based Bullying or Teasing Experienced at School in Last Year

    Locations

    WBV was most commonly reported in general group settings, including the classroom (80%), the stairs/hallway (77%), and the cafeteria (70%) (Table 4). Sport-related locations such as the gym, PE class, sports practice, or athletic field (73%) and locker rooms/bathrooms (65%) were also reported by the majority of participants. More than one-half of youth reported experiencing WBV on the computer (65%) or phone (58%).

    TABLE 4

    Common School Settings in Which WBV Was Experienced in the Last Year

    Teasing Due to Other Factors

    After body weight, the most commonly reported reason for being teased/bullied was appearance (89%), and 65% of participants reported this type of teasing/bullying at least sometimes (Table 1). Adolescents were also often teased for reasons not relevant to the self, including someone they were friends with (74%) or someone they were dating (65%). The least commonly reported reasons for teasing/bullying included religion (24%), disability (17%), and sexuality (15%).

    Regression Analyses: Risk of WBV

    With increasing body weight, participants were more likely to report WBV (Table 5). Adolescents with worse grades (mostly C’s and D’s) were also more likely to experience WBV. Participants’ reports indicated that 50% of their mothers were overweight and 46% of their fathers were overweight. The risk of reporting WBV was significantly higher for youth with 2 overweight parents compared with youth with no overweight parents.

    TABLE 5

    Logistic and Linear Regressions Predicting Risk and Frequency of WBV Experienced at School

    Adolescents with a healthy weight according to BMI were also at risk for WBV (Fig 1). The risk of being victimized due to one’s weight was lowest 1 SD below the reference population mean, and increased sharply after this point, eventually reaching a chance of almost 100% for respondents with the highest BMI.

    FIGURE 1

    Logistic cubic spline regression model predicting risk of WBV across the observed range of participant BMI. Spline knots were created at every SD across the observed BMI range to capture the nonlinear relation between BMI and the risk of WBV. Outcome: “ever victimized at school” (0 = no, 1 = yes), predictor: BMI for age (z scores; mean: 10; SD: 1 in the reference population,40 sample mean = 11), N = 301.

    These analyses were conducted by using the full sample of adolescents.

    Types of Victimization

    Reported types of WBV were further examined according to participant characteristics. Linear regression models indicated that the frequency of different types of WBV or total WBV remained similar across participant characteristics with a few exceptions (Table 5). Obese students reported more verbal teasing compared with their nonoverweight peers, and students with lower grades reported more verbal, physical, and cyberbullying compared with students with mostly A grades.

    Discussion

    To the best of our knowledge the current study is the first to conduct an in-depth assessment of experiences of WBV in weight loss treatment–seeking youth. Results indicate that these adolescents are frequent targets of multiple forms of WBV in many settings on school campuses. It is further concerning that our findings suggest that WBV may be virtually inevitable for the heaviest youth, and that these youth have likely been targets of victimization for an extensive period of time.

    Several additional findings from the current study raise cause for concern. First, peers were reported to be extremely common perpetrators of WBV in the school setting, but it is noteworthy that more than one-half of the sample also reported bullying from unknown individuals. Given that more than one-half of participants reported experiencing WBV via cell phones or computers, it is likely that unknown individuals represent cyberbullies who use technology to retain their anonymity. Youth may feel increasingly vulnerable with an unknown bully or experience increased psychological distress (ie, depressive symptoms, suicidal ideation, self-injury, suicide attempts) if subject to cyberbullying in addition to other forms of bullying.45

    Second, of considerable concern is the high percentage of adolescents (37%) who reported WBV from their parents. Research indicates that weight-based teasing from multiple sources (eg, peers and parents) may be associated with increased emotional health problems for youth.19 When treating an overweight or obese child, clinical intervention involves interactions with the child’s parents to equip them with the tools to improve the health of their child, as well as that of the whole family. As part of these efforts, our findings highlight the need for providers to educate parents about WBV and to offer them appropriate strategies to address their child’s weight with sensitivity and support. Even well-intentioned parents may inadvertently criticize or tease their overweight children in ways that are extremely damaging.19,26,4648 For those youth who are targets of WBV at school and at home, health care providers may be among their only remaining allies. Thus, it can be especially helpful for providers to promote adaptive coping strategies (eg, positive self-talk, social support, problem-focused coping)18,48,49 during patient visits with youth who are targets of WBV.

    Third, youth were often teased/bullied because of people they were associated with, including friends (74%), dating partners (65%), and family members (32%). In light of our finding that having 2 overweight parents increases youth risk of WBV, it is possible that youth may be experiencing proximity bias (as discussed by Hebl and Mannix50); namely, obesity stigma is extended to individuals closely associated with an obese person. Future research should examine whether body weight of a family member, friend, or dating partner increases an adolescents’ likelihood of victimization.

    Finally, our findings suggest that formerly overweight youth who have lost weight and whose BMI is currently in the healthy weight range may still be vulnerable to WBV, which aligns with recent research indicating formerly obese females experience continued stigma after weight loss.51 Thus, providers should be aware that risk of WBV may be present for youth of diverse body weights and not just for those who are currently overweight or obese.

    A primary limitation of this study is its self-report format. This format may introduce bias in the reporting of perceived experiences of victimization, as well as weight and height information. However, previous research has demonstrated generally high concordance between child and maternal reports of victimization,52 and between self-reported weight and height data and measured values of height and weight among adolescents.53 Finally, we did not assess participant socioeconomic status, and thus it is not known if this sample overly represents individuals with the financial means to attend such a program.

    Conclusions

    Our findings show that weight loss treatment–seeking adolescents experience pervasive weight-based torment from classmates and adults, which has important implications for clinical intervention and treatment with this population. Pediatric providers, school personnel, and program staff can help these youth by looking for signs of teasing, bullying, or associated psychological distress such as depression and anxiety, identifying whether youth have a support system in place to deal with WBV, sharing concerns about bullying with parents, and assisting in efforts to obtain mental health services or other resources for youth in need of support. With increased recognition of WBV, providers can play an important role in helping to reduce the damaging impact of victimization on the quality of life for youth struggling with their weight.

    Acknowledgments

    The authors are grateful to Camp Shane and Wellspring Camps for their cooperation and project support, with specific thanks to Ziporah Janowski and Dan Kirschenbaum.

    Footnotes

      • Accepted July 24, 2012.
    • Address correspondence to Rebecca M. Puhl, PhD, Rudd Center for Food Policy and Obesity, Yale University, 309 Edwards St, New Haven, CT 06511. E-mail: rebecca.puhl{at}yale.edu
    • Dr Puhl conceptualized the project and design, interpreted findings, led the writing, and approved the final manuscript as submitted; Ms Peterson reviewed relevant literature, contributed to study measures, managed data collection, contributed to paper drafts and revisions, and approved the final manuscript as submitted; and Mr Luedicke analyzed the data, interpreted results, created tables, contributed to writing, and approved the final manuscript as submitted.

    • FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

    • FUNDING: Research and project support were provided by the Rudd Center for Food Policy and Obesity.

    • COMPANION PAPERS: Companions to this article can be found on pages e10 and e288, online at www.pediatrics.org/cgi/doi/10.1542/peds.2012-1180 and www.pediatrics.org/cgi/doi/10.1542/peds.2012-3253.

    References