Body Image 1 (2004) 155–167

Body image and psychosocial differences among stable average

weight, currently overweight, and formerly overweight women:
the role of stigmatizing experiences
Natasha Milkewicz Annis a , Thomas F. Cash a,b,∗ , Joshua I. Hrabosky a
a Virginia Consortium Program in Clinical Psychology, Norfolk, VA, USA
b Department of Psychology, Old Dominion University, Norfolk, VA 23529, USA

Received 22 August 2003; received in revised form 31 December 2003; accepted 31 December 2003

Abstract

Substantial research has compared obese and nonobese persons on body image and psychosocial adjustment. While differences
in body satisfaction are often observed, the literature is less clear on other dimensions. Extant differences are typically thought
to result from the social stigmatization and maltreatment experienced by obese persons, especially females. The present study
of 165 women compared three cohorts who were currently overweight, never overweight, or formerly overweight. Relative to
never-overweight women, currently overweight women reported more body dissatisfaction/distress, overweight preoccupation,
and dysfunctional appearance investment, as well as more binge eating, lower social self-esteem, and less satisfaction with life.
Consistent with the “phantom fat” phenomenon, formerly overweight women were comparable to currently overweight women
but worse than never-overweight women on overweight preoccupation and dysfunctional appearance investment. Correlations
confirmed that, among overweight but not formerly overweight women, more frequent stigmatizing experiences during childhood,
adolescence, and adulthood were significantly associated with currently poorer body image and psychosocial functioning.
Scientific and clinical implications of the findings are discussed.
© 2004 Elsevier B.V. All rights reserved.

Keywords: Overweight; Obesity; Body image; Phantom fat; Weight stigma; Weight loss

Introduction 30.0 kg/m2 ) based on the 1999–2000 NHANES

Obesity has become one of the greatest health
epidemics in the world (Björntorp, 2002; Wadden,
Brownell, & Foster, 2002; World Health Organization,
1998). Among adults in the United States, the
age-adjusted rates of obesity (body mass index ≥
∗ Corresponding author. Tel.: +1-757-683-4439;
fax: +1-757-683-5087.
E-mail address: tcash@odu.edu (T.F. Cash).
data were 34.0% for women and 27.7% for men,
and with the inclusion of overweight persons (body
mass index = 25.0–29.9), these rates climb to 62.0
and 67.0%, respectively (Flegal, Carroll, Ogden, &
Johnson, 2002). During this same period, among chil-
dren ages 6–11 years, 16.0% of boys and 14.5% of
girls were overweight, and among adolescents ages
12–19, 15.5% of both boys and girls were overweight
(Ogden, Flegal, Carroll, & Johnson, 2002). These
rates reflect significant increases in the prevalence of

1740-1445/$ – see front matter © 2004 Elsevier B.V. All rights reserved.
doi:10.1016/j.bodyim.2003.12.001
156 N.M. Annis et al. / Body Image 1 (2004) 155–167
overweight or obesity relative to the NHANES data
from 1988 to 1994.
In view of Western society’s exacting standards of
physical appearance and its discriminatory “anti-fat”
attitudes and behaviors, it should be no surprise that
obese individuals experience psychosocial conse-
quences of their weight. Friedman and Brownell’s
(1995) meta-analysis on the psychological correlates
of obesity found few identifiable differences between
obese and nonobese persons. They argued, however,
that prior research has often compared two very
heterogeneous populations (obese and nonobese),
examined only obese persons seeking weight loss,
used limited measures, or lacked appropriate con-
trols. Therefore, the conclusion of no psychosocial
differences between obese and nonobese individu-
als may be premature (Wadden, Womble, Stunkard,
& Anderson, 2002). Friedman and Brownell (1995,
2002) have concluded that obesity might cause major
psychological difficulties for some individuals, mild
problems in some, and perhaps no distress in others.
One of the most reliable psychological correlates of
overweight and obesity is body dissatisfaction (Cash
& Roy, 1999; Friedman & Brownell, 1995; Sarwer,
Wadden, & Foster, 1998; Schwartz & Brownell, 2002,
2004). If an individual’s social environment regards
her or him as unattractive, it should not be surpris-
ing that the obese individual will internalize this
self-view. Although obese individuals may or may not
be more likely to distort their body size (Schwartz &
Brownell, 2004), they are more dissatisfied with their
appearance and are more avoidant of social situations
in comparison to nonobese people (Rosen, 2002;
Sarwer et al., 1998; Schwartz & Brownell, 2004).
Within the overweight and obese population, as well
as within the general public, women are more likely
to express body dissatisfaction and distress than their
male counterparts (Cash & Roy, 1999; Schwartz &
Brownell, 2002, 2004). A negative body image can
have adverse psychosocial consequences, including
disordered eating (Cash & Deagle, 1997; Stice, 2002),
depression (Noles, Cash, & Winstead, 1985), social
anxiety (Cash & Fleming, 2002a), impaired sexual
functioning (Wiederman, 2002), and poor self-esteem
(Powell & Hendricks, 1999). Cash and Fleming
(2002b) and Cash, Jakatdar, and Williams (in press)
found an inverse relationship between women’s body
mass and body image quality of life, which refers to
the impact of body image on daily life experiences.
This relationship remained even after body dissatis-
faction was statistically controlled.
A number of risk factors contribute to, or are as-
sociated with, body image dissatisfaction and distress
in overweight or obese individuals. Binge eating dis-
order (BED) has been identified as a correlate, not
only of body image problems, but also of a number
of psychosocial difficulties among the obese (Mussell
et al., 1996). Overall, findings suggest that individuals
who binge, regardless of their weight, reveal sig-
nificantly greater psychological distress on standard
measures of psychopathology, have a more negative
body image, lower levels of self-esteem, and a higher
lifetime prevalence of psychiatric illness, particu-
larly affective disorders (Bartlett, Wadden, & Vogt,
1996; Berman, Berman, Heymsfield, & Fauci, 1992;
French, Jeffery, Sherwood, & Neumark-Sztainer,
1999; Webber, 1994). Although the Diagnostic and
Statistical Manual of Mental Disorders (DSM-IV-TR;
American Psychiatric Association, 2000) does not in-
clude body image disturbance as a criterion for BED,
researchers argue that significantly elevated levels of
dysfunctional body image attitudes regarding weight
and shape are a major characteristic of the disorder
(Cargill, Clark, Pera, Niaura, & Abrams, 1999; Grilo,
2002). It appears, therefore, that body image and
binge eating are associated.
A second possible risk factor for increased body
dissatisfaction in obese individuals is the stigma and
discrimination that they experience in their daily
lives (Neumark-Sztainer & Haines, 2004). As the
rates of overweight and obesity in the United States
are rapidly increasing, Western society perpetuates
messages that being thin means being beautiful and
successful in many areas of life (Jackson, 2002;
Tiggemann, 2002). In contrast, being overweight
connotes ugliness, morbidity, laziness, and personal
failing (Puhl & Brownell, 2001, 2002). Such negative
attitudes have come to be “one of the last socially ac-
ceptable forms of discrimination” (Puhl & Brownell,
2002, p. 108). Stigma and discrimination can be found
in a wide range of life domains, including employ-
ment (Pingitore, Dugoni, Tindale, & Spring, 1994;
Roehling, 1999), medical and health care (Foster
et al., 2002; Harvey & Hill, 2001; Hebl & Xu, 2001;
Price, Desmond, Krol, Snyder, & O’Connell, 1987),
and formation of relationships in childhood (Anesbury
 N.M. Annis et al. / Body Image 1 (2004) 155–167
& Tiggemann, 2000; Bell & Morgan, 2000; Cramer
& Steinwart, 1998). Prejudice against obese individ-
uals begins at a young age and lasts throughout the
lifespan. For instance, Cramer and Steinwart (1998)
found that preschool children endorsed a negative
stereotype about fat persons, and that as children
grow older their negative beliefs strengthen. Col-
lege students have described obese people as more
self-indulgent, less self-disciplined, and less attrac-
tive than average weight individuals (Lewis, Cash,
Jacobi, & Bubb-Lewis, 1997), stereotypes that tend to
be shared by overweight persons themselves (Lewis
et al., 1997; Tiggemann & Rothblum, 1988).
Some overweight or obese individuals face difficul-
ties in their abilities to function in interpersonal situ-
ations. Recreational activities may be constrained due
to physical discomfort or social rejection (Lean, Han,
& Seidell, 1999; Myers & Rosen, 1999). Although
Berman et al. (1992) found that a significant number
of treatment-seeking obese individuals were limited or
isolated in their social relationships, Miller, Rothblum,
Brand, and Felicio (1995) discovered that obese and
nonobese women did not differ in social competence,
social network size, or perceived social support from
friends and family. Obesity may reduce opportuni-
ties for dating and marriage, especially among women
(Gortmaker, Must, Perrin, Sobol, & Deitz, 1993; Stake
& Laurer, 1987). Finally, Cash, Beskin, and Yamamiya
(2001) found that weight was modestly positively re-
lated to physical self-consciousness during sex among
college women.
Quality of life seems to improve after weight loss,
including an increase in social and physical activ-
ities (Isacsson, Frederiksen, Nilsson, & Hedenbro,
1997), better relationships with others, including
spouses (Chandarana, Conlon, Holliday, & Deslippe,
1990), better body image (Cash, 1994; Foster,
Wadden, & Vogt, 1997), and improved sexual func-
tioning (Chandarana et al., 1990). Although these
findings suggest that quality of life may be impaired
in overweight or obese persons, studies are based
on clinical samples seeking weight loss, are some-
times retrospective, and are far from comprehensive
in tapping all facets of quality of life.
While weight loss may lead to increased body
satisfaction, some formerly overweight persons may
also experience “phantom fat”, whereby they remain
weight-concerned and retain some degree of body
157
dissatisfaction despite weight loss (Adami et al.,
1998; Adami, Meneghelli, Bressani, & Scopinaro,
1999; Cash, Counts, & Huffine, 1990). Formerly,
overweight individuals’ greater body image concerns
compared to weight-matched, never-overweight indi-
viduals evinces this phenomenon. On the other hand,
some research has not confirmed phantom fat, such
that formerly overweight individuals reported body
satisfaction equivalent to average-weight controls
(Cash, 1994; Foster et al., 1997). The current study
reexamines this issue.
The purpose of this research was to examine and
compare body image and psychosocial functioning
among three groups of women. Only women were
studied given the evidence that, relative to men, they
are at greater risk for psychosocial difficulties when
overweight (Cash & Roy, 1999; Friedman & Brownell,
1995). Three nonclinical cohorts were studied: (a) now
overweight (NOW) individuals, defined as women
who have been overweight for at least the past 3 years;
(b) formerly overweight (FOW) individuals, who
were overweight at some time in their life for at least
6 months, excluding pregnancy, and have been aver-
age weight for the past 2 or more years; and (c) stable
average weight (SAW) individuals, who have main-
tained an average weight throughout their lifetime.
These groups were assessed on dimensions of body
image, self-esteem, social anxiety, depression, eating
behaviors, quality of life, and perceived weight-related
stigmatization. We sought to answer these empirical
questions: Do SAW and FOW women report signif-
icantly better body image, self-esteem, eating behav-
iors, affect, and quality of life compared to women
who are currently overweight (NOW)? Furthermore,
to examine the phantom fat phenomenon, what are the
differences between weight-matched SAW and FOW
women? Finally, among NOW and FOW women, is
weight-related stigmatization associated with current
body image and psychosocial functioning?
Method
Participants and recruitment
The sample consisted of 165 women from commu-
nity (n = 65) and university populations (n = 100),
both from the mid-Atlantic region of the United States.
158 N.M. Annis et al. / Body Image 1 (2004) 155–167
Participants were 18 years of age or older. College
participants responded to announcements posted on
the campus, and community participants responded to
flyers posted at local exercise facilities and advertise-
ments in local print media and on the internet. The lat-
ter was posted on a Weight Watchers website, which
produced only five participants. Weight was not ex-
plicitly mentioned in advertisements. College students
received extra credit in their courses for participation.
Community volunteers were eligible to win one of
nine raffle prizes from $25 to $100.
Participants’ ages ranged from 18 to 81 (M = 30.4,
SD = 14.0). Regarding ethnicity, 70% of participants
were European American, 20% African American, 6%
Asian, 2% Hispanic, and the remaining 2% were of
other or unspecified ethnicity. Seventy-seven percent
of participants completed or were in the process of
completing college, 9% completed or were in the pro-
cess of completing graduate school, and 13% com-
pleted high school only. One-half of participants were
single, 21% were cohabitating or married, and 16%
were separated, divorced, or widowed.
Classification of weight groups
Participants were ultimately classified as either
currently overweight (NOW), formerly overweight
(FOW), or stable average weight (i.e. never over-
weight). Current body mass index (BMI, kg/m2 ) was
calculated based on self-reported height and weight.
Average weight is defined as a BMI between 18.5 and
24.9; overweight is a BMI from 25.0 to 29.9; and obe-
sity is defined as a BMI of 30.0 or higher (Björntorp,
2002). Participants completed a weight history ques-
tionnaire that obtained height, lowest weight and
duration, and highest weight and duration. To supple-
ment these data, participants were asked whether and
when they had been overweight by at least 10 pounds
(excluding pregnancy) and completed figural rating
scales for largest body size. Because recollections of
height and weight from childhood are apt to be unre-
liable, we used Collins’s (1991) seven figural stimuli
for childhood (age 4 to pre-puberty), with figures 5, 6,
and 7 reflecting “overweight”. Being NOW required
a BMI ≥ 25.0 for at least the past 3 years (n = 58).
There were 42 FOW women who had been average
weight for the past 2 or more years but were over-
weight for at least 6 months at some previous time
(based on BMIs for adolescence and adulthood and
on self-labeled “overweight” and figural choices for
childhood). SAW included 65 women who had main-
tained an average weight throughout their lifetime.
Among NOW participants, 17% were overweight
and 83% were obese (BMI: M = 36.8, SD = 8.1).
BMIs of the SAW group ranged from 19.0 to 24.9
(M = 21.7, SD = 1.7), and BMIs of the FOW group
ranged from 18.7 to 24.8 (M = 22.1, SD = 1.9).
Histories indicated that 67% of the FOWs and 62%
of the NOWs were overweight as children, and 67%
of FOWs and 78% of NOWs were overweight as
adolescents. Chi-square analyses indicated that these
were not significant differences. Whereas by defini-
tion 100% of NOW women were overweight as adults,
this was true of 45% of FOW women. Finally, 21%
of FOW participants had been overweight during all
three periods, and this was the case for 57% of the
NOW group, χ2 (1) = 12.58, p < 0.001.
Procedures and assessments
After an informed consent procedure, participants
anonymously completed a battery of standardized
measures of body image and psychosocial function-
ing, as well as a demographic and weight history
form. College participants returned materials to an
on-campus office; community participants mailed
them in a pre-stamped envelope.
Multidimensional Body-Self Relations Questionnaire
(MBSRQ)
The MBSRQ is an attitudinal body image assess-
ment, using a 5-point disagree–agree response format
(Brown, Cash, & Mikulka, 1990; Cash, 2004). This
study used three MBSRQ appearance subscales: The
7-item Appearance Evaluation subscale assesses pos-
itive and negative appraisals of one’s physical appear-
ance. Its reliability (Cronbach’s alpha) in this sample
was 0.92. The 4-item Overweight Preoccupation sub-
scale assesses fat anxiety, weight vigilance, dieting,
and eating restraint, with an internal consistency of
0.72 in this study. The 9-item Body Areas Satisfaction
Scale (BASS) measures the degree of dissatisfaction
or satisfaction with specific body areas and attributes
(e.g., face, weight, muscle tone, etc.). Its internal con-
sistency was 0.84.
 N.M. Annis et al. / Body Image 1 (2004) 155–167
Situational Inventory of Body Image Dysphoria
(SIBID)
The SIBID (Cash, 2002, 2004) is a 48-item measure
that assesses negative body image emotions in various
situational contexts. For each item, participants rate
the frequency of dysphoric emotions on a 5-point scale
ranging from 0 (“Never”) to 4 (“Always or Almost
Always”). Its internal consistency was 0.98.
Appearance Schemas Inventory (ASI)
The ASI (Cash & Labarge, 1996) is a 14-item mea-
sure assessing dysfunctional body image investment
surrounding the meaning and importance of one’s
physical appearance (e.g. “I should do whatever I
can to always look my best.” “What I look like is
an important part of who I am.”). Participants rate
items on a 5-point disagree–agree scale. Its internal
consistency in this sample was 0.87.
Texas Social Behavior Inventory (TSBI)
The TSBI (Helmreich & Stapp, 1974) is a 16-item
measure of social self-esteem. Participants rated a se-
ries of self-statements on a 5-point scale from 0 (“not
at all characteristic of me”) to 4 (“very characteristic
of me”). High composite scores (summed items) in-
dicate positive social self-esteem. Its internal consis-
tency was 0.85.
Fear of Negative Evaluation—short form (Brief FNE)
The Brief FNE is a 12-item measure of anxiety
in anticipation of being evaluated negatively by oth-
ers (Leary, 1983). Participants rate themselves on a
scale from 1 (“not at all characteristic of me”) to 5
(“extremely characteristic of me”), with higher scores
reflecting greater social-evaluative anxiety. The Brief
FNE had an internal consistency of 0.92 in the current
sample.
Center for Epidemiological Studies—Depressed
Mood Scale (CES-D)
The CES-D (Radloff, 1977) is a 20-item measure
of depressive symptomatology during the past week,
rated on a Likert-type scale, ranging from 1 (“rarely
or none of the time, or less than 1 day”) to 4 (“most or
all of the time, or 5–7 days”). Its internal consistency
was 0.89.
159
Extended Satisfaction With Life Scale (ESWLS)
The 50-item ESWLS developed by Alfonso,
Allison, and Rader (1996) assesses satisfaction within
nine domains of life: general life, social life, sexual
life, relationship, self, physical appearance, family
life, school life, and job satisfaction. Each subscale
contains five items, with the exception of the 10-item
job satisfaction subscale. Each item is rated on a
7-point Likert-type scale, ranging from 1 (“strongly
disagree”) to 7 (“strongly agree”). The ESWLS de-
rives an overall composite score. Items that were not
applicable (e.g., for unemployed persons or those
not in school) were prorated (i.e., mean of answered
items X 50). The measure’s internal consistency in
this sample was 0.94.
Binge Eating Scale (BES)
The BES (Gormally, Black, Daston, & Randin,
1982) is a 16-item scale designed to assess binge
eating feelings, cognitions, and behavioral manifes-
tations (e.g., preoccupation with restraint of eating,
guilt, eating in secret, eating fast). For each item, par-
ticipants choose one of three or four response options
that best describes their eating-behavior experience.
Its internal consistency was 0.92.
Stigmatizing Situations Questionnaire—Extended
(SSQ-E)
This SSQ (Myers & Rosen, 1999) was adapted and
expanded for this current study. The original SSQ
contained 50 items for overweight stigma experienced
during adulthood. We dropped two items that were
related to childhood stigma. Our expansion contained
53 items for overweight stigma during adolescence
and 25 items for stigma during childhood. Exemplary
items are: “Being called names, laughed at, or teased
by your peers.” “Being excluded from extracurricular
activities . . . because of your weight.” “Losing a job
because of your size.” “Being stared at in public.”
“Not being able to find clothes that fit.” Thus, the
extended 126-item measure assesses stigmatizing
situations encountered and the emotional impact of
these in adulthood, adolescence, and childhood. Items
reflected themes of fat stigmatization rated from 0
(“never occurred”) to 9 (“occurred daily”) and the
emotional impact of each situation rated from 0 (“not
upsetting”) to 4 (“very upsetting”). The original SSQ
was reliable (α = 0.95) and discriminated between
160 N.M. Annis et al. / Body Image 1 (2004) 155–167

severely obese and mild to moderately obese per-
sons (Myers & Rosen, 1999). We calculated a stigma
frequency score and a stigma impact score. Because
these two scores were highly correlated (rs ranged
from 0.88 to 0.90), we analyzed only the stigma
frequency index. Internal consistency of the scales
measuring stigma in childhood, adolescence, and
adulthood were 0.94, 0.95, and 0.94, respectively.
Demographic and historical data sheet
This form obtained information on age, ethnicity,
marital status, education, height, weight, and weight
history (described previously).
[χ2 (2, N = 163) = 7.34, p < 0.05], understandably
because the NOW women were older.
Body mass index
A GLM ANOVA on BMI indicated a significant dif-
ference among groups [F(2, 162) = 164.7, p < 0.01,
η2 = 0.67]. Post-hoc analyses revealed that, as in-
tended, NOW participants were significantly heavier
than FOW and SAW participants. There was no dif-
ference between FOW and SAW participants. Group
means and standard deviations were provided previ-
ously.

Differences in body image

Results
A composite score was computed based on
participants’ averaged normalized (z) scores on three
Preliminary analyses
moderately to highly correlated variables: the MB-
SRQ Appearance Evaluation subscale, Body Areas
Prior to performing inferential analyses, we ex-
Satisfaction scale, and the reverse-scored SIBID. This
amined whether their assumptions were met. All
composite score reflects participants’ reported dissat-
dependent variables were normally distributed. The
isfaction with their appearance, as well as the body
assumption of homogeneity of variance was slightly
image distress felt across various situations. Lower
violated in a few analyses; however, analysis of vari-
values reflect greater dissatisfaction and distress.
ance (ANOVA) is robust to this violation if there are
The GLM ANOVA on this body image index indi-
no outliers and sample sizes are relatively large and
cated a significant difference among the three groups
equal (Tabachnick & Fidell, 2001). Post-hoc Tukey
(p < 0.001). As shown in Table 1, NOW participants
HSD tests were performed if the overall ANOVA for
had significantly lower scores than the FOW and
the group comparisons for each scale was significant
SAW groups, suggesting appreciably greater body
(p < 0.05).
image dissatisfaction/distress among NOW women
General-linear-model (GLM) one-way between-
(p < 0.001). The FOW group had a marginally poorer
groups ANOVAs were performed on continuous de-
body image relative to the SAW group (p < 0.08).
mographic variables. There was a significant differ-
ANOVAs also indicated that both NOW and FOW
ence in age among the three groups [F(2, 162) = 7.35,
participants experienced significantly greater over-
p < 0.01]. Post-hoc tests revealed that NOW group
weight preoccupation (MBSRQ) and dysfunctional
participants (M = 35.8, SD = 14.8) were signifi-
appearance investment (ASI) than did the SAW group
cantly older than FOW (M = 28.4, SD = 12.8) and
(ps < 0.001). NOW and FOW women did not differ.
SAW (M = 26.9, SD = 12.7) participants.1 There
were no significant educational differences among
Differences in psychosocial functioning
the groups. Chi-square tests compared groups on
nominal demographic variables. They did not differ
Table 1 further summarizes results of ANOVAs on
in ethnicity; however, the NOW women were more
self-esteem, social anxiety, depression, quality of life,
likely to be married than were FOW and SAW women
and binge eating. NOW participants reported poorer
social self-esteem than SAW participants (p < 0.05),
1 The study’s principal analyses were also conducted by con- and reported less overall satisfaction with their life and
trolling for age as a covariate. As results were not substantively more symptoms of binge eating than both FOW and
altered, only the uncontrolled analyses are reported. SAW participants (ps < 0.001), who did not differ.
 N.M. Annis et al. / Body Image 1 (2004) 155–167 161

Table 1
Comparison of groups on body image and psychosocial functioning
Measures M (SD) F-value Effect size
(partial η2 )
Currently Formerly Stable average
overweight overweight weight
Body image
Body image dissatisfaction/distress −0.74 (0.70) a 0.20 (0.81) b 0.51 (0.68) b 48.63∗∗ 0.38
Overweight preoccupation 3.15 (0.86) a 3.36 (0.92) a 2.62 (1.03) b 8.98∗∗ 0.10
Dysfunctional appearance investment 2.98 (0.63) a 2.79 (0.70) a 2.45 (0.64) b 10.37∗∗ 0.12
Psychosocial functioning
Social self-esteem 52.9 (10.1) a 54.1 (8.7) ab 57.0 (8.9) b 3.22∗ 0.04
Social anxiety 37.9 (11.7) 36.3 (11.0) 34.1 (9.4) 1.99 0.02
Depression 16.7 (9.8) 16.9 (10.4) 13.5 (9.9) 2.10 0.03
Life satisfaction 188.1 (54.8) a 238.8 (36.1) b 248.5 (31.5) b 33.73∗∗ 0.30
Binge eating 19.03 (10.4)a 8.79 (8.14) b 9.59 (8.85) b 20.89∗∗ 0.21
Means that do not share a common letter are significantly different.
∗ p < 0.05.
∗∗ p < 0.001 (df = 2, 158–162).

There were no significant group differences in social
anxiety (p = 0.14) or depressive symptoms (p =
0.13).
Differences in perceived stigmatization
ANOVAs compared NOW and FOW groups on
childhood, adolescent, and adulthood overweight
stigmatization. Sample sizes varied across analyses
because participants completed the measure only for
the period(s) in which they were overweight. The
absence of significant differences between NOW
and FOW groups indicated that currently overweight
women experienced as much stigmatization at each
period as their formerly overweight peers.
Relationship between perceived stigmatization and
body image
Pearson correlations between perceived stigmatiza-
tion and body image are reported in Table 2. For the
NOW group, childhood, adolescent, and adulthood
stigmatization were all significantly related to greater
body image dissatisfaction/distress (at least p < 0.01),
more dysfunctional appearance investment (at least
p < 0.01), and more overweight preoccupation (at
least p < 0.05). For the FOW group, there were no re-
liable relationships between stigmatization at any pe-
riod and the three body image measures. Of course, the
very small sample size of FOW women overweight as
adults precludes detection of significant associations.

Table 2
Pearson correlations between stigmatization history and body image
Body image measures Childhood stigmatization Adolescent stigmatization Adulthood stigmatization

NOW (n) FOW (n) NOW (n) FOW (n) NOW (n) FOW (n)

Body image dissatisfaction/distress −0.58∗∗ (31) −0.34 (28) −0.53∗∗ (30) 0.14 (26) −0.56∗∗∗ (51) 0.06 (13)
Overweight preoccupation 0.48∗∗ (31) 0.26 (28) 0.36∗ (30) 0.14 (26) 0.50∗∗∗ (51) 0.03 (13)
Dysfunctional appearance investment 0.53∗∗ (30) 0.21 (28) 0.55∗∗ (29) 0.13 (25) 0.39∗∗ (50) 0.33 (12)
∗ p < 0.05.
∗∗ p < 0.01.
∗∗∗ p < 0.001.
162 N.M. Annis et al. / Body Image 1 (2004) 155–167

Table 3
Pearson and partial correlations between stigmatization and psychosocial functioning
Psychosocial functioning measures Childhood stigmatization Adolescent stigmatization Adulthood stigmatization

NOW (n) FOW (n) NOW (n) FOW (n) NOW (n) FOW (n)

Social self-esteem
Pearson r −0.40∗ (29) −0.45∗ (26) −0.46∗ (28) 0.26 (24) −0.32∗ (49) 0.12 (11)
Partial r −0.19 (28) −0.39∗ (25) 0.29 (27) 0.23 (23) −0.11 (48) 0.10 (10)
Social anxiety
Pearson r 0.62∗∗∗ (29) 0.46∗ (26) 0.59∗∗ (28) −0.17 (24) 0.44∗∗∗ (49) −0.05 (11)
Partial r 0.46∗∗ (28) 0.35 (25) 0.44∗ (27) −0.12 (23) 0.22 (48) −0.03 (10)
Depression
Pearson r 0.45∗ (29) 0.18 (26) 0.51∗∗ (28) 0.05 (24) 0.37∗∗ (49) 0.21 (11)
Partial r 0.33 (28) 0.04 (25) 0.42∗ (27) 0.12 (23) 0.23 (48) 0.25 (10)
Life satisfaction
Pearson r −0.53∗∗ (28) −0.04 (26) −0.53∗∗ (27) −0.15 (24) −0.43∗∗ (48) −0.02 (10)
Partial r −0.38∗ (27) −0.02 (25) −0.40∗ (26) −0.16 (23) −0.26 (47) −0.03 (9)
Binge eating
Pearson r 0.54∗∗ (29) 0.06 (26) 0.59∗∗∗ (28) −0.06 (24) 0.54∗∗∗ (49) 0.32 (11)
Partial r 0.22 (28) −0.03 (25) 0.35 (27) −0.03 (23) 0.21 (48) 0.35 (10)
Partial correlations controlled for the body-image composite score.
∗ p < 0.05.
∗∗ p < 0.01.
∗∗∗ p < 0.001.

Relationship between perceived stigmatization and
psychosocial functioning
Pearson correlations between perceived stigma-
tization and psychosocial functioning are given in
Table 3. For the NOW group, stigmatization at all
periods was significantly related to all psychosocial
adjustment indices. Childhood, adolescent, and adult-
hood stigmatization were related to lower self-esteem
(at least p < 0.05), greater social anxiety (at least
p < 0.01), more depression (at least p < 0.05), less
life satisfaction (ps < 0.01), and more binge eating
(at least p < 0.01). For the FOW group, childhood
stigmatization was related to lower social self-esteem
(p < 0.05) and higher social anxiety (p < 0.05), but
was not correlated with depression, satisfaction with
life, or binge eating. There were no significant rela-
tionships between adolescent or adult stigmatization
and any measure of psychosocial functioning of the
FOW women. Again, adulthood observations were
too few to be reliable.
To determine if perceived stigmatization is related
to psychosocial adjustment independent of body im-
age, partial correlations were computed, controlling
for body dissatisfaction/distress. Table 3 presents the
results. For the NOW group, childhood stigmatization
remained significantly related to more social anxiety
(p < 0.01) and poorer quality of life (p < 0.05).
Adolescent stigmatization remained significantly as-
sociated with lower quality of life and higher levels of
social anxiety and depressive symptoms (ps < 0.05).
However, stigmatization in adulthood was no longer
related to any of the psychosocial adjustment variables
nor to social self-esteem or binge eating at any pe-
riod. For the FOW group, childhood stigmatization re-
mained significantly related to lower self-esteem (p <
0.05), but was not correlated with any other mea-
sures. Adolescent and adulthood stigmatization were
still uncorrelated with the psychosocial functioning
measures.
Discussion
Excessive weight can lead to increased risk of a
variety of medical conditions, ranging from diabetes
mellitus to cardiovascular disease (Pi-Sunyer, 2002).
Yet it is obesity’s potential psychosocial consequences
 N.M. Annis et al. / Body Image 1 (2004) 155–167
and vulnerabilities that are less understood. These
vulnerabilities stem from numerous risk factors, in-
cluding the stigma associated with overweight and
obesity (Cash & Roy, 1999; Puhl & Brownell, 2001,
2002). To evaluate the nature and scope of psychoso-
cial difficulties associated with being overweight
or obese, we compared three nonclinical groups of
women who were currently overweight (NOW), for-
merly overweight during childhood, adolescence, or
adulthood (FOW), or never overweight (SAW). The
majority (83%) of the NOW women were obese. The
SAW and FOW groups had an equivalent current
BMI. The three groups were compared on measures
of body image, social self-esteem, social anxiety,
depression, quality of life, and binge eating.
Congruent with previous research (for reviews, see
Cash & Roy, 1999; Schwartz & Brownell, 2002, 2004)
and predicted findings, NOW women reported greater
body dissatisfaction and distress than either FOW or
SAW women, with the FOW group experiencing a
marginally (p < 0.08) poorer body image than the
SAW group. FOW and NOW women did not dif-
fer in extent of overweight preoccupation or dysfunc-
tional appearance investment. However, both groups
reported greater overweight preoccupation and dys-
functional investment than did SAW women who had
never been overweight. These findings suggest that
while formerly overweight women may not continue
to suffer from significant dissatisfaction or distress
about their appearance, possibly because they have
lost weight, preoccupation about their weight and ap-
pearance persists.
Thus, our results provide clarifying evidence of
“phantom fat” in formerly overweight women (Adami
et al., 1998, 1999; Cash et al., 1990; Foster & Matz,
2002), and begin to shed light into the specific dif-
ficulties these women endure. At least 2 years after
losing weight, these women no longer appear to be
so dissatisfied with their body, but still are signifi-
cantly cognizant of and anxious about their weight
and hold schematic beliefs about salience or influence
of their appearance in their lives. Whereas sustained
weight loss brings more body image satisfaction (see
Foster & Matz, 2002; Sarwer & Thompson, 2002),
perhaps the threat of weight gain and the past expe-
riences of social adversities do not completely dis-
sipate. Moreover, for those who have lost very large
amounts of weight, the body may possess reminders
163
of their former obesity, such as flabby skin, wrinkles,
or cellulite (Sarwer & Thompson, 2002). Heinberg,
Thompson, and Matzon (2002) have also argued that
some moderate level of body image concern may
adaptively motivate weight loss (and maintenance).
In the face of improved body satisfaction, perhaps
continued weight vigilance and some anxiety about
becoming fat (again) may promote healthy eating
and exercise behaviors in the prevention of weight
regain.
Studies comparing obese and nonobese individu-
als on measures of social anxiety, depression, and
self-esteem have often found no differences (Friedman
& Brownell, 1995). However, many of these stud-
ies were poorly designed and consisted only of
treatment-seeking patients. The current research used
established measures of psychosocial functioning and
life satisfaction and also included a formerly over-
weight group. Results indicated no group differences
on social anxiety or depression, suggesting obesity
alone does not heighten the risk of these difficulties.
However, NOW women reported significantly poorer
social self-esteem than did SAW women, and FOW
women did not differ from either NOW or SAW
women, suggesting that social self-esteem may be
partially restored with moderate weight loss.
Currently overweight women reported significantly
more binge eating pathology relative to both FOW
and SAW women, who did not differ. Our expected
finding of more binge eating among NOW women
is consistent with evidence they are more likely
to engage in binge eating than nonobese individ-
uals (Schwartz & Brownell, 2004; Smith, Marcus,
Lewis, Fitzgibbon, & Schreiner, 1998; Telch, Agras,
& Rossiter, 1988; Wilfley, Wilson, & Agras, 2003;
Womble et al., 2001).2 Our FOW participants may
have engaged in less binge eating prior to and after
weight loss, therefore enabling these women to lose
weight and maintain weight loss.
2 To provide supplementary evidence of the relations between
binge eating and body image and psychosocial functioning among
overweight women, we calculated Pearson’s correlations with the
BES. Among NOW participants, binge eating was related to greater
body-image dissatisfaction/distress (r = −0.71, p < 0.001), dys-
functional appearance investment (r = 0.42, p < 0.001), poorer
social self-esteem (r = −0.51, p < 0.001), greater social anxiety
(r = 0.49, p < 0.001) and depression (r = 0.47, p < 0.001), and
less satisfaction with life (r = −0.37, p < 0.005).
164 N.M. Annis et al. / Body Image 1 (2004) 155–167
In addition to assessing for pathology, we exam-
ined life satisfaction or “quality of life” across a range
of domains (i.e., general, social, sexual, self, appear-
ance, family, relationship, school, and work). NOW
women reported a poorer quality of life relative to
both the FOW and SAW women, who did not differ.
This was the largest effect size among the psychoso-
cial functioning measures (partial η2 = 0.30), second
only to body image dissatisfaction/distress (partial
η2 = 0.38). These findings may reflect the greater ad-
versities that overweight or obese women encounter
in their daily lives. Although this is a cross-sectional
study, the results for the FOW group may indicate that
when overweight women successfully lose weight
and maintain the loss, they experience an increase in
overall quality of life.
Another purpose of our study was to examine the
moderating role of stigmatizing experiences on the
body image and psychosocial functioning of over-
weight and formerly overweight persons. We adapted
the Stigmatizing Situations Questionnaire (Myers &
Rosen, 1999) to assess the frequency of perceived
stigma during overweight periods in childhood, ado-
lescence, and adulthood. No differences were found
between NOW and FOW groups, at any period, indi-
cating equivalent degrees of stigma when overweight,
regardless of current weight. Findings for the NOW
group overwhelmingly supported our hypothesis that
stigmatization history would be associated with cur-
rently greater body image disturbance. More perceived
stigma in childhood, adolescence, and adulthood was
moderately related to greater body image dissatisfac-
tion/distress, weight preoccupation, and dysfunctional
beliefs about appearance. Moreover, as hypothesized,
among NOW women, stigmatizing experiences at
each period were associated with currently lower
social self-esteem and life satisfaction, and greater
social anxiety, depression, and binge eating. Although
we cannot infer causality, stigmatization does show a
consistent relationship to lower levels of functioning
among NOW women (Neumark-Sztainer & Haines,
2004).
These findings for the NOW group stand in marked
contrast to those for the FOW group, for whom stigma
history and current body image were unrelated (al-
though small sample size prevents a conclusion for
adulthood stigma). Only two significant correlations
occurred between stigmatization and psychosocial
functioning among formerly overweight women.
Those who experienced more stigma in childhood
also reported poorer social self-esteem and greater so-
cial anxiety. These data suggest that after a period of
sustained weight loss, past experiences of stigma may
have less bearing on one’s body image and psychoso-
cial functioning. In effect, successful weight loss
may trump many of these stigmatizing experiences,
whereas among women who remain overweight, such
experiences continue to impact their psychological
well-being. Perhaps this is because currently over-
weight persons continue to experience social stigma,
which activates their emotion-laden schemas about
their body, whereas those who have lost weight no
longer have to deal with intolerance in their environ-
ment and may actually receive positive reinforcement
(e.g., compliments, support, new clothes, etc.) for
their thinner body type.
To clarify the relationship between stigmatization
and psychosocial functioning, apart from body image
disparagement, we computed partial correlations con-
trolling for body image dissatisfaction/distress. For
NOW women, childhood stigmatization remained sig-
nificantly related to social anxiety and quality of life,
and adolescent stigmatization was still associated with
depression, social anxiety, and quality of life. None of
the psychosocial functioning measures remained re-
lated to adult stigma. Our findings suggest that stigma-
tizing experiences in childhood and adolescence may
be internalized for long periods of time and may have
a lasting impact on functioning in adulthood among
overweight women, regardless of their body satisfac-
tion or dissatisfaction. For the FOW group, after con-
trolling for body image, the significant relationship
between childhood stigmatization and poorer social
self-esteem remained. The FOW group reported stig-
matizing experiences comparable to the NOW women
throughout life, yet seemed to be largely unaffected
by these experiences after weight loss. Perhaps the re-
duction of weight-related stigma in their current lives
reduces the impact of past prejudice and discrimina-
tion.
Despite its strengths and contributions to the liter-
ature, this research is not without limitations. Given
its cross-sectional design, we cannot reach causal
conclusions that losing weight is responsible for
the observed differences between currently and for-
merly overweight women. Group classifications were
 N.M. Annis et al. / Body Image 1 (2004) 155–167
derived in part from recollections of body size rather
than from objective historical data. Prospective re-
search is needed to elucidate the findings of this study.
Reports of stigmatization are retrospective and could
be autobiographically biased, although it is reassuring
that NOW and FOW groups did not differ in their
reports. Furthermore, as indicated, the number of
observations in some analyses had diminished power.
Our research provides clear evidence that the great-
est difference between overweight women and those
who were previously or never overweight is a more
negative body image and a poorer quality of life.
Further, it suggests that the cumulative prejudice and
discrimination that overweight persons face in their
lives is negatively related to their well-being. Unfor-
tunately, most weight management programs do not
systematically evaluate or address body dissatisfaction
(Rosen, Orosan, & Reiter, 1995) or stigmatization,
despite the fact that effective cognitive-behavioral
body image treatments are available (Cash &
Hrabosky, 2004; Cash & Strachan, 2002). Recently,
some clinical researchers have been incorporat-
ing such procedures in their programs (Cooper &
Fairburn, 2002; Foster et al., 1997). Addressing body
image disparagement in weight management programs
may help reduce maladaptive weight preoccupation
if weight is lost and/or partially regained. Because
many people are unsuccessful in maintaining initial
weight loss, learning to increase body acceptance,
as well as learning to manage the stigma associated
with weight, could potentially enhance quality of life.
Finally, as Schwartz and Brownell (2004) assert “One
potentially dangerous conclusion that could be drawn
from the idea that even some body image distress is
beneficial is that societal discrimination and stigma
are justified because they may help motivate people
to change.” (p. 53)
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