Introduction  

The proportion of people who are overweight or live with obesity has increased continuously over the past decades.1 In Germany, the current Health Interview and Examination Survey for Adults reports a prevalence rate of obesity (defined as body mass index, BMI ≥30 kg/m²) of approximately 24%.2 The aetiology of obesity is multifaceted, different factors such as behavioural, biological, psychosocial, context-related or prenatal conditions concur.3 However, poor diet and sedentary behaviour are often erroneously seen as the primary reason for overweight.4 This, in turn, lays the focus on individual responsibility and fosters public stereotypes of laziness and weak will. According to attribution theory, believing the condition to be under a person’s control determines greater stigmatising reactions.5 The public misconception of causes of overweight and obesity is common and contributes to the expression of obesity stigma.6 Individuals with overweight or obesity display a physical ‘mark’ that sets them apart from others. Link and Phelan7 have provided a process model, in which stigma is conceptualised as several distinct, but interrelated steps: differences between social groups are distinguished and labelled. These labels are linked to stereotypes (undesired characteristics) that form the basis of a separation of ‘us’ and ‘them’. Thusly labelled individuals experience status loss and discrimination in a context in which power is exercised.

There is a public recognition of obesity as a chronic condition and it is a classified disease in some countries (but not Germany).8 Nevertheless, individuals with obesity experience discrimination in daily life, which, in turn, reinforces negative stereotypes and stigmatising processes.7 Ascribing negative attributes, such as unintelligent, lack of self-discipline or emotionally instable9 10 to persons who are obese, activates processes that result in discrimination in different settings. This could be shown for the education and employment sector as well as personal relationships.10 Furthermore, stigmatising attitudes and discrimination are present in the healthcare sector, possibly leading to the avoidance of necessary treatment.11 The adverse health consequences of obesity stigma have been shown on psychological (eg, depression, self-esteem) and physical (eating behaviour, physical activity, cardiovascular health outcomes) levels.10

One German study found that about one-fourth of the general public displays stigmatising attitudes regarding the ‘Weight Control/Blame’ subscale from the Antifat Attitudes Test.12 High levels of responsibility for becoming obese are attributed to the individual, which is associated with the belief that the individual should be liable for treatment costs to a great extent.13 Sikorski et al examined emotional reactions and social distance towards individuals with obesity and found that the most rejected domains were personal ability as well as social interaction.14

In terms of gender differences, studies reported higher weight bias internalisation15 and greater risk for weight/height discrimination16 among women. In children and adolescents, girls with overweight have been found to be subject to teasing and social marginalisation.17 18 Similar results are presented by Fikkan and Rothblum,19 who found women with obesity to be more stigmatised in education and employment sectors than men. However, gender differences in obesity stigma have rarely been examined, and results are not consistent.20

In recent years, stigma research has paid increased attention to multiple social identities and their interaction to influence stigmatisation. This intersectional approach allows examining how multiple social categories, for example, being categorised as ‘female’, ‘black’ or both, interact to produce or protect against health risks or discrimination.15 This may be referred to as ‘multiple stigma’21 or ‘double disadvantage’.22 These concepts suggest that a person can belong to different, possibly stigmatised social groups which exerts cumulative effects.23 When it comes to obesity stigma at the intersection of gender and race, few studies have been conducted and results were inconsistent. Himmelstein et al15 found no divergences in obesity stigma according to race or gender, whereas Puhl et al found that African-American females with obesity evoked higher ratings of dislike and social distance than Caucasian females with obesity.24 It has been postulated by Grey that severe and extreme obesity compounds pre-existing socioeconomic inequalities in context of vulnerability.25 However, to date, no study has focused on the possible additive or multiple effects of gender and socioeconomic status (SES) in the context of obesity stigma. This is astonishing, as there are socioeconomic inequalities in the prevalence of obesity.26 This also holds true for Germany, where obesity is more common among children and adults who are of low SES. Women in this group appear to be excessively affected by obesity.27

Against this background, we analyse differences in public stigma towards low versus high SES persons as well as female versus male persons with obesity. By incorporating the interaction of gender × SES, we additionally examine possible interdependencies and their associations with obesity stigma.

Methods

Results

Sociodemographic characteristics of the analysed sample are briefly presented in table 1. The male:female ratio is relatively even, which is similar to the general adult population in Germany according to the official statistics.45 In terms of age, people aged 25–39 years are under-represented and people aged 60–64 years are over-represented in the sample compared with the distribution in the official statistics.46 Almost half of the respondents work in occupational positions that are regarded skill level 2 when referring to ISCO.44 Regarding weight status, more than 50% of the respondents reported overweight or obesity. The share of those with overweight/obesity corresponds to numbers obtained by other representative studies in Germany.2 The vast majority (84.4%) has or had personal contact to someone who is overweight.

In tables 2–4, differences in the mean stigma values depending on SES and gender presented in the vignette are reported. Regarding the fat phobia items, the adjective low self-esteem was ascribed to the female vignette significantly more often (respective means were 3.10 for the female vignette and 2.83 for the male vignette, table 2). In contrast, lazy, slow and self-indulgent were significantly more often attributed to the male vignette. Comparing low and high SES, a homogeneous picture emerged. A low SES was significantly associated with greater negative attitudes, expressing individual responsibility (no willpower, poor self-control, weak) as well as insecurity and low self-esteem when compared with high SES.

Regarding emotional reactions (table 3), the comparison of gender in the vignette showed that males with obesity evoked significantly more negative emotional reactions on four out of six items as well as on the subscale for negative emotions (respective means were 9.67 for the female vignette and 10.54 for the male vignette). In terms of SES, a cleaner/janitor with obesity evoked significantly more feelings of anger but also more positive emotional reactions, compared with a lawyer with obesity.

A consistent picture emerged when comparing desire for social distance according to the person’s gender in the vignette (table 4). Males with obesity were met with significantly greater levels of rejection in most aspects of social distance. Gender difference was also significant for the desire for social distance scale (13.15 for males and 11.66 for females). Similarly, a person with obesity and a low SES evoked greater desire for social distance concerning four of seven items. Also, the desire for social distance scale significantly differed between the SES vignettes (13.03 for low SES and 11.72 for high SES).

The results of multiple linear regression analyses are reported in table 5. While controlling for respondents’ characteristics, a significant main effect of SES emerged regarding fat phobia (β = 0.173). Being a janitor or cleaner with obesity was associated with significantly increased fat phobia compared with lawyers. Regarding positive emotional reactions, there were no significant associations with either gender or SES. However, male persons with obesity were confronted with more negative emotional reactions than females (β=−0.151). In terms of desire for social distance, both main effects were statistically significant. Being either a male or a janitor/cleaner with obesity was significantly associated with greater desire for social distance. In none of the models did the interaction effect of gender × SES attain statistical significance (table 5).

Discussion

The concept of multiple stigma suggests that a person can belong to different potentially stigmatised groups, experiencing an aggregation of disadvantages and discrimination.23 Applying this approach to the present study, this would mean that because of their group affiliation (eg, being female and of low SES), individuals suffer multiple stigma when confronted with the burden of obesity. Similarly, the framework of intersectionality describes the interdependent relationship between different social identities and structural inequities.47 Multiple social categories interact and produce or protect against discrimination. In light of this, obesity stigma can reinforce pre-existing inequalities because of SES and/or gender.

The present study is the first to analyse the possible multiple stigma of gender, SES and obesity. Following an intersectional approach, it was analysed whether main effects or the interaction of social categories possibly reinforce obesity stigma, implying a double or multiple disadvantage for certain individuals. While there were no statistically significant interaction effects of categories, we found distinct differences in obesity stigma dependent on gender with regard to different stigma components. Males with obesity were met with more negative emotional reactions and social distance. This contradicts some previous studies that found (young) women with overweight or obesity to be met with greater stigmatisation than men.15–19 The predominance of overly thin women in the media and the promotion of a slim beauty ideal for females can have different effects on the stigmatisation of women and men with obesity.20 Nevertheless, over the past decade, a trim and muscular male body image has come to the fore in most Western societies, shaping a new perspective on body image dissatisfaction and obesity stigma also among men.48 49 Men have been found to be similarly stigmatised as women for being heavy,20 and the concern about body image is associated with increased eating pathology in both men and women.50

Regarding SES and obesity, the study revealed significant differences in public attitudes in several stigma components under study. Those of low SES were rated less favourably with regard to fat phobia and desire for social distance when compared with persons with high SES. On the other hand, individuals with low SES were also met with significantly greater prosocial feelings. It is possible that, next to obesity, the status of a cleaner/janitor is linked to characteristics (eg, economic hardship) that evoke pity among respondents. After the adjustment of respondents’ characteristics in the multivariate analyses (gender, age, BMI, occupational position as well as contact to an individual with obesity), however, only the associations with fat phobia and social distance were found to be significant.

Following the concept of intersectionality, and against the background of a disproportionate distribution of obesity (higher prevalence among females of low SES), one could have expected significant interaction effects in multivariate analyses. We were not able to verify this assumption. However, significant main effects of gender and SES indicate a double stigma to the disadvantage of males as well as individuals with a low SES who suffer from obesity.

Some limitations need to be mentioned and discussed when evaluating our findings. More than half of the individuals eligible for the study were not available or refused to participate. Although participation rates around 50% can be regarded satisfactory for telephone surveys,32 we cannot rule out selection bias due to nonresponse. With respect to internal consistency, Cronbach’s α for most scales was good or acceptable. Only the subscale of positive emotional reactions exhibited limited reliability, which could be due to the relatively small number of items. In this case, it is recommended to use the mean inter-item correlation as an indicator for acceptability, which was 0.22 in the present sample. A satisfactory range is said to be 0.2–0.4.51 Furthermore, no conclusions on causal relationships can be drawn as our data are based on a cross-sectional design. Similar to other studies in stigma research, we used vignettes to explore possible multiple stigma of obesity. On the one hand, these should not be too long. On the other hand, only varying one sentence to express different social conditions might have been too short to convey a holistic picture of the individual, or to be kept in mind throughout the whole interview. Also, vignettes had to be understandable for the general population. Therefore, we decided not to report the BMI and not to use the term ‘obese’. In this regard, it can be considered a limitation that the vignettes lack medical accuracy. Moreover, due to time constraints, every respondent only received one vignette. The lack of a neutral control condition impedes the interpretation of results. For example, it remains unclear whether respondents associate adjectives such as low self-esteem or insecurity with the fact that the individual in the vignette presented with obesity or pursues the profession of a janitor when compared with a lawyer. This is a limitation that has to be considered when interpreting our findings as an indication of multiple or double stigma. Finally, sample size may have been too small to detect significant interaction effects.

Differences in stigma based on gender and SES indicate that obesity can exacerbate pre-existing inequalities. The presence of obesity stigma could be shown in many domains of daily life, for example, education, work, personal and healthcare.10 11Stigmatisation is a risk factor for physical and psychological health problems such as depression, body dissatisfaction and low self-esteem. Instead of motivating individuals to lose weight, stigma is associated with additional weight gain6 and underutilisation of healthcare.11 This implies a vicious circle of mutually reinforcing negative conditions. The manifold effects of obesity stigma require actions in all kinds of professional disciplines, for example, among physicians, dieticians and scientists in various fields. To counteract stigma, the topic should be the subject of discussion in obesity intervention measures, and anti-stigma messages have to be incorporated into obesity prevention campaigns. Our results underline the need to consider the social dimension of obesity stigma. In acknowledging the interrelation of social conditions and existing structures, future research should derive tailored measures to encounter obesity stigma and its related adverse physical and psychological health outcomes.