‘ EAL n. L". 1%.; 3 . "16" -,. rant-{‘2‘}; flap-Eun- 1*.) 3a ,5 z. ,1 até'k‘r‘ai‘ 1. ,n-U . Fifi-3319323 L > - . $19k L13; - w '_-_ mi”:- a wrap. , . nut-m}, . 1... »7 1.1. “are." x "$21 fly {3. N K n. 'LC-«ul; ‘30:“. 7‘ 5' In. 11‘%£‘%Y 734“ ‘31:}: '3'??ng ,' -*« . .. ax 4. f; 23‘“. “$6“ *lllllllllllllllllllllllllllllllllllllll f 3 1293 01051 5371 This is to certify that the thesis entitled The Stigmatization of Obesity in Early to Middle Adolescence presented by Marcia Kay Kwantes has been accepted towards fulfillment of the requirements for Master's Human Nutrition degree in QQW MWQQM Major professor Date ‘3’39 '9 27 0-7 639 MS U is an Affirmative Action/Equal Opportunity Institution LIBRARY Michigan State University PLACE ll RETURN BOXto romovothb chookoutflom your mood. TO AVOID FINES Mum on or him dd. duo. DATE DUE DATE DUE DATE DUE JAN 27 1997 ‘ ll I l MSU lo An Affirmotlvo Action/EM Opportunity lnotttwon W m1 THE STIGMATIZATION OF OBESITY IN EARLY TO MIDDLE ADOLESCENCE BY Marcia Kay Kwantes A THESIS Submitted to Michigan State University in partial fulfillment of the requirements for the degree of MASTER OF SCIENCE Department of Food Science and Human Nutrition 1994 ABSTRACT THE STIGMATIZATION OF OBESITY IN EARLY TO MIDDLE ADOLESCENCE BY Marcia Kay Kwantes Obese people are stigmatized, and this stigmatization is most detrimental in adolescence. To learn more about how obesity is stigmatized at this time, 66 youth (17 boys and 49 girls) of various weight ranges, ages 11-15 years, participated in interviews. Participants responded to open- ended questions about their perceptions of obesity regarding weight loss, friendship and popularity. Interviews were audiotaped and transcribed; statements were coded and theoretically categorized. Results indicated youths' perception of acceptable weight is influenced primarily by the media and peers. Some overweight peers were stigmatized, but others were not, apparently due to their friendships and popularity through sports. A conceptual model was developed of the process of stigmatization and nonstigmatization of obese youth. Additionally, results will be used to develop 1) a quantitative survey to measure stigmatization and 2) an intervention program to help overweight youth cope with stigmatization. ACKNOWLEDGEMENTS To the members of my Guidance Committee: To Dr. Sharon Hoerr, Department of Food Science and Human Nutrition, who served as my major professor, her guidance was very much appreciated. Thank you for your helpful editorial comments as well as your help with posters and presentations. I appreciated your understanding of my unforeseen circumstances outside of my schoolwork and your encouragement in the past two years. To Dr. David Kallen, Department of Pediatrics and Human Development, whose knowledge and expertise with qualitative research as well as with adolescents was invaluable. Thank you for your encouragement and confidence and time you gave toward this research project. To Dr. Rachel Schemmel, Department of Food Science and Human Nutrition, whose writing and organizational skills brought this project together in a more understandable way. I thank you for your helpfulness and insightfulness you gave me as a teaching assistant and for treating me as a coworker. To the Institute for Children, Youth and Families who supported this project financially as well as gave many iii opportunities to allow this project to be publicized. To Linda Hudson who I have great respect for and who helped me many times with writing letters and copying papers and gave me a smile to cheer up my day. Thank you to the many undergraduate work-study students who helped with typing the interviews. To Terri Carson, Darlene Zimmerman, Heather Wells, Jia- Yau Doong, Chia-Yen Tsai, Madhuri Yagalla, Ya-Li Huang for the encouragement and enjoyment you gave to my graduate school experience. Thanks to Therese Bednowicz whose friendship and support and laughter will never be forgotten. Thanks to my Mom and Dad Kwantes and my Mom and Dad Lankheet and my sister Brenda Roels whose encouragement and support through prayers, letters and phone calls meant a lot to me. Finally, and most of all, I would like to thank my husband Mike for encouraging me to go on for more education and for being a constant support through this graduate program. iv TABLE OF CONTENTS Chapter II. List of Tables List of Figures INTRODUCTION Research questions Glossary REVIEW OF THE LITERATURE Qualitative Data Collection Focus group interviews Development\Use of Grounded Theory Stigmatization of obesity What is stigmatization? Who stigmatizes? Adolescent Obesity: Prevalence, Health Consequences and Impact on Physical and Emotional Development Prevalence of obesity Unhealthy weight losing patterns Health risks Weight loss programs for adolescents Physical development ‘ Relationship of development to psychosocial factors Gender differences in the effects of stigma Stigmatization of obesity and self-esteem Stigmatization and self-concept Stigmatization and body image Summary 10 10 10 11 12 12 13 17 17 18 19 19 20 20 21 21 23 24 25 III. IV. VI. METHODS Glossary of terms Generating theory Recruitment and description of subjects Procedures Development of Instruments Demographic and body image questionnaire Interview questions Analysis Collection of Categories A Collection of Categories B Development of the conceptual model and questionnaire RESULTS AND DISCUSSION Sources of adolescents' preconceived ideas about weight Media Overweight worse for girls Teasing Athletics and teasing Treatment from teachers Disadvantages and consequences of being overweight Causes of overweight and weight loss Adolescents' definitions and stigmatization of overweight Defining "overweight", "fat" and "obese" Nonstigmatization Describing big friends and big strangers How overweight youth get popular Advantages of being overweight Other considerations Desired group attention Consequences of friendship with an overweight peer Development of the conceptual model Draft of questionnaire Limitations and Strengths SUMMARY Implications for treatment APPENDICES A Recruitment of participants B UCRIHS letter vi 26 26 27 28 31 33 33 34 37 37 39 40 41 43 43 45 48 54 54 56 59 64 64 69 69 76 79 81 81 82 83 86 88 90 92 94 9S Consent forms Demographic and Body Image Profile Question Set #1 and #3 Categories A An example of a coded interview An example of Ethnograph analysis Categories B HEQHIEIUO LIST OE REFERENCES vii 97 100 102 106 112 118 122 125 Table 3.0 LIST OF TABLES Number of subjects by demographics in Group 1, Group 2 and Group 3. Matrix of type of interview questions, subjects and instruments used to generate theory for stigmatization of obesity in youth. Question Set #2. Refined interview questions for how obesity is stigmatized in youth. An outline of results and discussion. Reasons given by respondents for why overweight is worse for girls or for boys. Reasons given by youth for who teases, what teasers do, and why youth tease overweight youth. Disadvantages and consequences of being overweight given by boys and girls. Reasons given by boys and girls for causes of overweight and ways to lose weight for overweight peers. Concepts used by boys and girls to define the word "overweight", "fat" and "obese". Words used to describe friends and strangers whose weight for height is ‘ greater than socially accepted standards. Responses given from youth about how overweight youth get popular. .Responses youth gave about advantages of overweight for boys and for girls irrespective of respondent's gender. viii Page 30 34 35 42 46 49 58 60 66 70 78 8O Figure 3.0 LIST OF FIGURES Study design for generating theory of stigmatization of obesity in youth. The conceptual model of the process of stigmatization of obesity in youth. Draft of the questionnaire, including constructs, to measure stigmatization of obesity in youth. ix Page 28 85 87 Chapter I INTRODUCTION The prevalence of obesity in school age youth ranges from 5-25% in the United States (Rossi, 1992) to 20-40% in Michigan (Hoerr et al., in press). The United States has identified Health Objectives for the Year 2000 to reduce the prevalence of overweight in adolescents (USPHS, 1991), because of the adverse health effects obesity has during adolescence (Aristimuno et al., 1984) and into adulthood (Must et al., 1992). Therefore, much emphasis has been placed on treatment and prevention of obesity in youth through various weight management techniques. Traditional weight management interventions with obese adolescents are now being called into question and health professionals do not have good substitutes. Many weight loss programs do not look at the social and psychological aspects that are associated with obesity (Kinston et al., 1988) and few show weight management success over the long term for adolescents (Pena et al., 1989; Mellin et al., 1987; Wadden et al., 1990). The etiology of obesity and success of weight management, therefore, is complex and is 2 not as simple as our society thinks. Health professionals, the media and our society in general have influenced perceptions of appropriate weight for adolescents to improve health and appearance. There are many youth, however, who are above the appropriate weight "standards". What happens to these youth socially and how do they get treated by others, if they do not meet those "standards"? Does their treatment from others have a relationship to success or failure with weight management? An important social issue this study will investigate is the stigmatization associated with obesity, specifically in adolescents. Stigmatization is the social process through which individuals who have certain characteristics are devalued by others (Goffman, 1963). Evidence suggests that the obese are stigmatized and viewed by others as less valuable than average weight people in society (Allon, 1979, 1980; Czajka- Narins and Parham, 1990; Sobal, 1984). Whereas in some cultures overweight is a sign of beauty and wealth (Cahnman, 1968), in many other cultures overweight is socially undesirable and such persons thought to be lazy, greedy and self indulgent (Canning and Mayer, 1966; Maimon et al., 1979; Allon, 1980; Strauss, 1985). The time when stigmatization is most debilitating is during adolescence when the self is still in the process of being formed (Staffieri, 1967; Stunkard and Burt, 1967). 3 This "self" is influenced by others who are important to the adolescent such as parents, siblings and teachers (Rice, 1984). Another important part to an adolescent's social and psychological development is the sense of belonging to a group and being accepted as a worthy person by peers in and out of the classroom setting (Goodenow, 1993; East et al., 1987). Stigmatization of obesity negatively affects the obese child or adolescent (Richardson, et al., 1961; Allon, 1979; Taitz, 1983). Continuing blame and insensitive remarks toward an obese young person by peers may result in withdrawal from normal activity such as exercise (Cahnman, 1968). The messages obese adolescents receive about their bodies may negatively affect their self-esteem, self-concept and ability to socialize with peers (Israel and Shapiro, 1985; Monello and Mayer, 1963; Miller et al., 1990). The possibility that stigmatization of obesity hinders efforts toward weight management has been suggested by Allon (1979), but has not been investigated in adolescents. If there is a relationship between social stigma and obesity in adolescents, then efforts to help cope with and control the stigma associated with obesity should help with weight management. Before these efforts can be initiated, understanding the process of stigmatization in youth is necessary. To understand and "uncover" the little information 4 known about stigmatization of obesity in youth, a qualitative data collection is most appropriate (Strauss and Corbin, 1990; Stewart et al., in press). Qualitative data collection techniques are desirable to obtain information about a behavior (Krueger, 1988; Morgan, 1988; Patton, 1987). Here, such techniques as interviews and focus groups are useful to gain insight for why youth act towards overweight peers the way they do. Information about how obesity is stigmatized would likely be missed if a quantitative data collection technique such as a questionnaire was used based on assumptions of adult investigators. An understanding of the process of the stigmatization of obesity will provide a foundation to develop a quantitative tool to measure stigmatization. Such a tool will identify adolescents at high risk for stigmatization and evaluate the effectiveness of an intervention against it. The purpose of this project is to 1) generate a theory of the process of stigmatization from qualitative data collection, 2) develop a conceptual model of the process of stigmatization of obesity in adolescents and 3) draft a quantitative tool to measure stigmatization. Research Questions 1. What perceptions and attitudes do adolescents have about other youth their age whom they perceive as being overweight? 2. What perceptions and attitudes do overweight adolescents have about their own weight and how do they think others see them? Objectives After interviews and focus groups are conducted and transcribed, the researchers will: 1. Identify common perceptions and attitudes adolescents have about overweight kids their age with regard to peer groups, weight loss, friendship and popularity. 9 Identify perceptions and attitudes overweight adolescents experience related to stigmatization. Generate a theory of the process of stigmatization of obesity in youth. Develop a conceptual model of the process of stigmatization of obesity in youth. Draft a quantitative tool to measure stigmatization in overweight adolescents. Stigma Body Image Self-esteem Self-concept Focus Group Physical Development QLQ§§AEX_QE_IEBM§ The social process through which individuals rwho have certain characteristics are devalued by others (Goffman, 1963) The adolescent's perceptions of his or her physique and appearance (Schiamberg, 1988). The extent to which a person feels positive about himself or herself (Gergen, 1971) The characteristics and attributes one applies to oneself (Schiamberg, 1988). A carefully planned discussion designed to obtain perceptions on a defined area of interest in a permissive, nonthreatening environment (Krueger, 1988). Changes, pertaining to the body, that an individual organism undergoes from its earliest form through its adult form (Rothenberg and Chapman, 1989). Growth Maturation Rate Puberty Adolescence Early Adolescence 7 Increase in size of an organism or any of its parts, as occurs normally in a child (Rothenberg and Chapman, 1989). The general tempo at which various biological, behavioral, and personal characteristics emerge and develop in they individual as a result of growth and development (Schiamberg, 1988). Refers to all the biological, physical, and sexual changes that occur as the individual moves from childhood to adulthood (Schiamberg, 1988). The period of development that begins with the onset of puberty and ends with the legal, social and psychological status of adulthood (Schiamberg, 1988) or the period of physical and psychological development from the onset of puberty to maturity (American Heritage Dictionary, 1982). The onset of puberty between the ages of 10-12 years in girls and 11-13 years in boys (Wright, 1984). Middle Adolescence Fat Overweight Obesity Grounded' Theory 8 The adolescent years of 12-15 in girls and 13-16 in boys (Wright, 1984). Type of body tissue (adipose) containing stored fat that serves as a source of energy, insulation, and as a protective cushion for vital organs (Rothenberg and Chapman, 1989) or Plumpness or obesity (American Heritage Dictionary, 1982). Weighing more than is normal, necessary, or allowed (American Heritage Dictionary, 1982). From a sociological standpoint, overweight and fat are interchangeable (Allen, 1982). Condition of being overweight; increase in the amount of fat in the subcutaneous tissues of the body (Rothenberg and Chapman, 1989). A qualitative research method that uses a systematic set of procedures to develop an inductively derived theory about a phenomenon (Strauss and Corbin, 1990). Qualitative Analysis Constant Comparative Method Social Self 9 A type of analysis that is guided not by hypotheses but by questions, issues, and a search for patterns (Patton, 1987). A method of joint coding and analysis to generate theory more systematically (Glaser and Strauss 1967). The person as he or she is known to himself or herself. The social self is developed, in part, from feedback received from significant others. Chapter 11 REVIEW OE THE LITERATURE Qualitative Data Collection In order to conceptualize the process of stigmatization and following a review of the literature (Krueger, 1988; Morgan, 1988; Strauss and Corbin, 1990; Stewart et al., in press), it was determined that a qualitative data collection technique was most appropriate to obtain information. A disadvantage to qualitative research is the small sample size which may not be representative of the population. However, according to Strauss and Corbin (1990), qualitative methods can be useful to "uncover and understand" areas of interest of which little is yet known and which would be difficult to understand with quantitative methods. Focus group interyiews One way to collect qualitative data is through focused interviewing of people in small selected groups. Focus group interviews obtain information about why people feel and think the way they do and do not limit responses to pre- delineated choices (Krueger, 1988). Focus groups were 10 11 selected as a cost effective method of data collection especially relevant to this study of how youth stigmatize obesity of their peers. The need for interviews and focus group techniques to gather qualitative data for theory building and ~ questionnaire development has been demonstrated by Glaser (1977) and Stewart et al. (in press). Focus group interviews have been helpful also in assisting with the development of conceptual models (Campbell et al., 1992) as well as in obtaining information about perceptions and attitudes of target audiences (Brown et al., 1992; Trenkner et al., 1991). Interviews in this research project were used to obtain perceptions from adolescents about obesity that could not be obtained or would likely be overlooked through "expert"- constructed questionnaires. With focus groups, particular observations of participants' perceptions of and attitudes towards obesity could be analyzed to identify general patterns of behavioral and attitude development (Patton, 1987). For example, a focus group can generate thoughts and attitude patterns about the process of stigmatization that an individual would not be able to do alone. eve o e t Us of ounded Theo The backbone of this research project rests on what the sociological literature calls grounded theory (Glaser and Strauss, 1967). According to Strauss and Corbin (1990), 12 "the grounded theory approach is a qualitative research method that uses a systematic set of procedures to develop an inductively derived theory about a phenomenon.... (A theory is) discovered, developed and provisionally verified through systematic data collection and analysis of data pertaining to that phenomenon." (p.23-24) Therefore, this project does not begin with a theory of the process of stigmatization in order to prove that theory, but rather begins with the phenomenon of stigmatization and through qualitative data collection, coding and analyzing develops a theory of the process of stigmatization. The theory is generated to develop a conceptual model and a tool to measure stigmatization. Stigmatization of Obesity Who; is stigmatization? The concept of stigmatization has been around for many years (Goffman, 1963). According to Sobal (1991), "a stigma is the negatively valued condition, while stigmatization is the interaction process of someone responding negatively to that condition.” (p.128) Obesity is a condition our culture views negatively (DeJong, 1980; Allon, 1979; Sobal, 1984). Obesity as well as other stigmatized conditions such as mental or physical handicaps, epilepsy, and physical deformities are present in our culture (Levison and Starling, 1981; Albrecht et al., 1982; Hermann et al., .1990). 13 In many cases, a stigmatized condition is viewed as "okay" by society, if the person cannot be held responsible for his or her condition (Rothblum, 1992; Weiner et al., 1988). Permissible conditions are those thought to be genetic as opposed to those due to character development. For example, blind people are not held responsible for their condition, as opposed to alcoholics who are. Who otiomatizes? Unlike other physical conditions such as blindness, society holds obese people responsible for their condition (Allan, 1982; DeJong, 1980; Rothblum, 1992). Despite the little information known about the causes of obesity, obese people are still seen as lazy, self-indulgent and weak- willed. Society influences the overweight person to the extent that many overweight people themselves believe they are responsible for their condition. Jeffery et al. (1990) reported that people in a weight loss program were more likely to blame themselves for their weight than people in a non-weight loss program. In another study, overweight men and women reported being aware of negative societal attitudes toward them but blamed themselves for their obesity (Harris, 1990). When the cause of obesity is a known medical problem, the obese person is held less responsible for his or her condition than an obese person with no medical problem. DeJong (1980) showed pictures of overweight and normal 14 weight females to 64 high school girls. Half of the participants were told the overweight girl in the picture was obese because of a thyroid problem. The other group was told nothing about the obese female. When participants thought the girl in the picture was obese because of a thyroid problem, they rated her the same as they rated a normal weight female. When participants were told nothing about the overweight girl, they liked her less and thought she was less self-disciplined, lazier and more self- indulgent than normal weight girls. Unfortunately, even health professionals, who should know the causes and "cures" of obesity are not well understood, still view the obese negatively (Maimon et al., 1979). Wiese et a1. (1992) surveyed first-year medical students about their knowledge of obesity and attitudes toward obese people. Although many had correct knowledge of the current information known about obesity, they still thought of obese people as lazy and lacking in self-control. Obese people, not only are accepted less into colleges and universities than non-obese people (Canning, 1966), but also, if accepted, are stigmatized on college campuses (Harris, 1983). This stigmatization continues after college also in social situations. Jasper and Klassen (1990) gave 80 undergraduate college students a description of a person they might work with after college. The description described either an obese male or female or a nonobese male 15 or female working in a Midwest-based company. Participants were to rank on a 7-point scale how eager they would be to work on a 3 month project with the described person. The results showed participants were significantly more eager to work with a nonobese person than an obese person. Recently, a new interpretation of the Americans with Disabilities Act has been discussed to allow all obese people, not just those who have a medical diagnosis as to the cause of their obesity, to be free from discrimination (Wall Street Journal, Nov. 12, 1993). This social problem has become severe enough that people are realizing action must be taken to prevent further discrimination. Attitudes toward a particular body build develop at an early age (Lerner and Schroeder, 1971; Lerner and Gellert, 1969; LeBow, 1988). Harris and Harris (1992) reported that in a rural southwestern United States community, children preferred a thin body build as opposed to a heavier one. When compared to other children with physical disabilities, the obese child was still the least liked (Maddox et al., 1968). Richardson and coworkers (1970) showed children drawings of other children on crutches, in a wheelchair, with facial disfigurements, with amputations or with obesity. With the exception of the amputee, the children disliked the picture of the obese child more than any of the other pictures. Children also associate body types with positive or 16 negative characteristics. Staffieri et a1. (1967) reported that 6-10 year old males preferred a mesomorphic or muscular, athletic body image and gave unfavorable adjectives to the endomorphic or obese body image. Similarly, Cohen and coworkers (1989) reported that first and third grade overweight boys were nominated less often for the most liked person in the class than the nonoverweight boys. Adolescents also favor the mesomorphic image. Dwyer and coworkers (1969) reported that 16-19 year old males preferred a mesomorphic image while the females preferred the mesomorphic and the ectomorphic (lean, linear) images. When describing an overweight figure, teens chose adjectives like "sad", "weak-willed", "stupid" and "bored" (Worsley, 1981). Likewise, Baum and Forehand (1984) demonstrated that overweight adolescents received more negative reactions from peers than average weight youth. Lebow and coworkers (1989) suggested negativity toward obesity by teenagers may be more apparent in the United States than in Canada. 17 do esc s t ' eva e ce ealt ons e c s an I act on sic t'o a eve 0 me t Erexalense_of_obs§itx_ Although it appears that all ages of overweight people receive negative messages about their bodies, the stigma associated with obesity may be most influential during adolescence (Allon, 1982; Dwyer, 1973; Sobal,1984). Negative feedback from adolescent peers at a crucial time in emotional development can result in a negative body image, low self-esteem and unhealthy weight losing patterns which could further impact any weight management efforts (Allan, 1979: Sobal, 1984). The high prevalence of obesity in youth, combined with negative social pressures, has led to a significant increase in adolescents trying to lose weight since the 1960's (Rosen, et al., 1987). These dieting concerns during adolescence are associated with eating disorders which have also increased dramatically over the past 20 years in adolescents and are associated with obesity (Hill, 1992: Mellin et al., 1992; Anderson and Domenico, 1992; Reiff and Reiff, 1992). 18 we' as t erns Although weight management may be an important aspect of a healthy lifestyle, adolescents receiving messages that their weight is unacceptable, and, therefore, tooy are unacceptable, may attempt unhealthy weight losing patterns (Moore, 1988; Richards et al., 1990). Adolescent girls are more concerned about their weight than boys (Gustafson- Larson and Terry, 1992), and frequently diet with little long term success (Casper and Offer, 1990). This quest for thinness combined with dieting failure has led to a preoccupancy with dieting and eating disorders (Hill, 1992). Moses et al. (1989) suggest that the fear of obesity in all weight ranges of adolescent girls puts them at a high risk of inappropriate eating patterns. Because girls are more likely to be concerned about weight than boys, they are more at risk of developing an eating disorder than boys (Richards et al., 1990; Hill, 1992). Mellin et al. (1992) surveyed 494 middle-class girls between the ages of 9 and 18 regarding attitudes associated with eating disorders. Participants were placed in a weight category according to relative weight (e.g., >120% considered very overweight). A fear of fatness and dieting were positively associated with weight category and body image distortion was negatively associated with weight category. 19 e 's s A final problem associated with adolescent obesity is the immediate and later health risks to the obese adolescent. An obese teen has a greater risk of high blood pressure and cholesterol leading to heart disease (Aristimuno et al., 1984). Must et al. (1992) conducted a follow up study on a group of men and women who participated in the Harvard Growth Study from 1922 to 1935. They found that participants that were overweight during adolescence, even if they lost weight during adulthood, had an increased risk of morbidity from coronary heart disease and atherosclerosis in both males and females, colorectal cancer and gout in men and arthritis in women. Woigot Loss Programs for Adolescents” Many weight loss programs for adults are not working because participants regain the lost weight over the long term (Wooley and Garner, 1991). Recidivism is similar in weight loss programs for youth. Many programs do not address body image or self-esteem (Bush et al., 1989; Zuckerman et al., 1989; King et al., 1988; Wadden et al., 1990). Others do not conduct follow up of more than a year (Killen et al., 1989; Pena et al., 1989; Vega et al., 1988). The inclusion of the psychosocial aspects of weight management for adolescents is an important consideration in programs for youth. 20 Physiogilooveloomeor Adolescence is a time of physical as well as emotional changes related to self-esteem, self-concept and body image. Concurrent with adapting to a new body and fluctuating emotional states, the adolescent needs to "fit in" socially to be accepted by peers, especially in regard to appearance (East et al., 1992; Lerner and Jovanovic, 1990; Dwyer, 1973). Physically attractive adolescents see themselves as more competent in social areas and have better peer relationships than adolescents who are not (Lerner et al., 1991) The physical changes or the pubertal process may be described in five stages (Tanner, 1962). Girls during this time in life deposit more fat than boys who typically decrease subcutaneous fat (Dwyer, 1973; Marino and King, 1980). Sobal (1989) suggests the increase in body fat in girls occurs at a crucial time when adult female values such as "becoming too fat" are instilled. One of the ways girls cope with these body changes is to restrict their food intake. It is not surprising, therefore, that girls reaching menarche tend to begin dieting at this time (Gralen et al., 1990). o o v o e choso l to s On the average, girls develop and mature about two years earlier than boys. Overweight females in childhood usually develop earlier than their female peers (Hediger and 21 Katz, 1986). Therefore, negative feelings about their body changes are much worse in overweight females than in their average weight friends (Peterson and Brooks-Gunn, 1988). These differences in growth patterns compared to peers could impact the overweight adolescent's self-image and relationships with peers (Sobal, 1984; Dwyer, 1973). gonoor difrorences in tho ogreots or srigma Although little information is known about the effects of stigma on adolescents, it appears that obese females are more stigmatized than obese males (Sobal, 1989). Feldman et al. (1988), in reviewing the literature, suggest that negative attitudes toward obesity are more evident in girls at a young age than in boys. Jackson (1992), in her review of the literature, found that females' overall attractiveness depended on weight distribution while males' attractiveness depended on the face. These conclusions may suggest that being overweight for adolescent males may be more acceptable than for adolescent females. St t'zation of Obes't and Self-esteem Self-esteem is "the extent to which the person feels positive about himself" (Gergen, 1971). Negative attitudes toward self can lead toward a low self-esteem. Crandell and Biernat (1990) gave questionnaires to 1072 undergraduates to understand anti-fat attitudes and self-esteem. The heaviest women in the sample had the lowest self-esteem and were more likely to have negative attitudes toward fatness than 22 average weight women. The authors concluded that being fat and disliking fatness have negative consequences for self- esteem. While some researchers argue that self-esteem is stable in seventh graders (Eccles et al., 1989), others find adolescence, especially starting in middle school or junior high, is a time when self-esteem is influenced and may contribute to obesity (Klesges and Hanson, 1988). Whereas Kaplan and Wadden (1986) found no differences in self-esteem between nonobese and obese black inner-city adolescents, others reported a negative relationship between weight and self-esteem in adolescents (Mandelson and White, 1985; Rosen et al., 1987). Self-esteem and weight issues seem to be of greater' concern to female adolescents than to males, resulting in more adolescent females on weight reduction diets than‘ males. Female adolescents, unhappy with their weight, were more likely to have lower self-esteem than those who were satisfied (Fisher et al., 1991). Richards and coworkers (1990) investigated the differences between fifth to ninth grade boys and girls regarding weight and self-esteem. Four hundred and eighty-one students were asked to carry electronic pagers with them during the day. When the pager signaled, students wrote out a summary of their current situation and a subjective self-report. Results showed that females were more concerned about weight than males 23 throughout the day. Low self-esteem and obesity in adolescents is an area that needs more investigation. Buckmaster and Brownell (1992) suggest that an overweight adolescent's score on a psychological test or even a self-esteem questionnaire may show everything is okay but will fail to show the adolescent's frustration with the inability to lose weight, the isolation he or she experiences from family and friends and the lack of understanding he or she receives from physicians. Stigmotizarion and selr-cooceot Self-concept, as described by Eccles et al. (1989) in their review of the literature, is a general sense of one‘s self-worth. Self-worth comes from the messages of others and how one interprets those messages. In a 1992 review, Buckmaster and Brownell reported that studies demonstrated the obese child as teased, and therefore a sense of body shame develops. If an obese child is receiving negatiVe messages about his or her body, it is not surprising obese children have been shown to have poorer self-concept than non-obese children (Sallade, 1973; Strauss et al., 1985). Folsom-Meek (1991) investigated the relationship of weight and self-concept in first through sixth graders. She found an inverse relationship between weight and self-concept scores. A serious problem with studying the relation of self-concept and self-esteem is that the measures may not be 24 sensitive enough to fully understand the effects of negative attitudes toward obese children (Buckmaster and Brownell, 1992). I Stigmatization and oooy imago The process of how body image develops is complex and influenced by many factors (Gordon'and Tobias, 1984). Children have favorable body images of themselves and higher self-esteem, if they perceive themselves as physically attractive and are perceived by peers as such (Lerner and Lerner, 1977). Adolescence is a time when a negative body image is more prominent than in adults, because it is a time of rapid physical changes (Cash et al., 1986). Therefore, it is not surprising that overweight teenagers have an even poorer body image than their average weight peers (Kertesz et al., 1992). Although body image may be poor during adolescence, studies have demonstrated that females are more concerned about their appearance than are males (Pliner et al., 1990; Altabe and Thompson, 1993). Women, and likewise adolescent girls, have more social pressure to lose weight and, therefore, are more likely to be dissatisfied with their weight and at greater risk of developing unhealthy weight loss patterns (Moore, 1988; Fallon and Rozin, 1985). 25 §BEE§£¥ The review of the literature for this research project shows the complicated, yet very important, role obesity plays in the psychosocial and physical development of adolescents. Therefore, it is imperative to understand and develop ways to help overweight youth cope with their situation and to improve self worth and social skills. te Categories A Categories 8 Group 1 Group 2 Group 3 Question Set #1 Question Set #2 Question Set #3 Transcription S Chapter III METHODS Theoretical categories developed from responses of participants in Group 1 and Group 2 (Appendix F). Theoretical categories developed from responses of participants in Group 3 in comparison to Categories A (Appendix H). Ten individual interviews and one focus group (n=16). Responses from this group were analyzed to develop Categories A and refine questions. Eleven focus groups and 4 individual interviews (n=37). Responses from this group were analyzed to develop Categories A. Ten individual interviews (n=10). .Responses from this group were analyzed to develop Categories B. Initial broad questions asked of Group 1 (Appendix B). Refined questions used for Group 2 (Table 3). Questions asked of overweight participants (Appendix F). A typewritten copy as transcribed or transferred from an audiotape recorded interview to paper. 26 27 Gooeratiog rheory To generate theory about the stigmatization of obesity in adolescents, a study design was based on the technique developed by Glaser and Strauss (1967) (Figure 3.0). Interviews began with relatively nonthreatening questions, asking about definitions and opinions of participants. As the interview progressed, more disclosing questions were asked about respondents' relationships and observations relating to overweight peers and the topic of weight. As information was obtained and understanding was developed, the focus of each area of inquiry became more clear and theoretical categories began to develop (Figure 3.0, Part 1). These theoretical categories were derived from the answers given to the questions. Responses from one person or focus group were compared carefully to the responses given by others in order to expand the theoretical understanding of each area and develop the first collection of categories (A) (Figure 3, Part 2). Questions were changed slightly to be appropriate for interviewing overweight participants; a new collection of theoretical categories (B) were developed (Figure 3, Part 3). Both collections of categories were then compared (Figure 3, Part 4) to understand the process of stigmatization of obesity in adolescents. Subjects, procedures and instruments used to collect data for this analysis are described in the following sections. 28 ‘ (Part 1) Initial broad Information Questions refined questions asked 9 obtained >and theoretical from youth categories developed Information obtained from youth (Part 3) (Part 2) Questions Information Comparison of changed and / obtained from Q _responses and Categories (BT‘ overwoight expansion of developed youth categories (A) (Part 4) Comparison of Categories A and B Figure 3.0. Study design for generating theory on stigmatization of obesity in youth (Glaser and Strauss, 1967). Bocroitment and Qescriotion of Subjects Data were collected at three different time periods (Groups 1, 2, 3) (Table 3.0). Sixty-three participants were in the targeted age range of 11-15 years old and three participants were 16-18 years old. Forty-nine girls and 17 boys were interviewed by means of an individual interview or a focus group consisting of 2-6 youth of the same gender. Three participants were excluded from the study because their responses were too poorly recorded on the audiotape of the interview to be transcribed. Subjects in Group 1 were recruited through inquiries of people in the Lansing community in April through June, 1992 29 (Table 3.0). Responses from 10 individual interviews and one focus group (n=16) were used to develop theoretical categories as a process of generating theory and to refine the initial questions. Data from 37 subjects in Group 2 (Table 3.0) were also used to develop theoretical categories as a process of generating theory (Part 2). Data from this second group were collected June through August, 1992. Youth from Group 2 were recruited from Michigan State University's 4-H Exploration Days and the Black Child and Family Institute in Lansing, MI. Data from 10 overweight subjects in Group 3 (Table 3.0) were used along with data from Groups 1 and 2 to generate theory. Overweight youth were interviewed individually to see possible differences in their responses compared to those from Groups 1 and 2. Three of the participants in Group 3 were ages 16-18 due to difficulties recruiting . overweight participants due to time constraints. Also, parents of overweight youth appeared reluctant to have their overweight son or daughter interviewed on this topic. Group 3 were recruited from the Lansing area schools, the Pediatric Clinic at Michigan State University and the Butterworth Shapedown weight management program in Grand Rapids, MI from February to June, 1993. Details on recruiting and interviewing for the 3 groups of participants can be found in Appendix A. 30 Table 3.0. Number of subjects by demographics in Group 1 (April-June, 1992), Group 2 (June-August, 1992) and Group 3 (February-June, 1993). Group 1 Group 2 Group 3 Totals Gender Girls 12 30 7 49 Boys 5 9 3 17 Ethnicity White 11 10 8 29 BlaCk 6 21 2 29 Hispanic 0 . 6 0 6 Other 0 2 0 2 Age in years 11-12 12 18 1 .31 13-15 5 17 6 28 16-18 0 0 3 3 BMI %tileb LOW 2 10 O 12 Average 6 19 0 25 High 2 9 10 21 ° Totals may not equal 66 participants because the demographic profile was developed after Group 1 and some participants left parts of the demographic profile blank. bSelf-reported weights. Low BMI= <15th percentile; Average=15th-85th percentile; High BMI= >85th percentile of NHANES II data for age and gender (NCHS, 1987). All adolescents in all three groups of interviews were ‘done on a volunteer basis and each participant paid five dollars. Participants were of different ages, races and weight ranges (Table 3.0). Weight, height, age and ethnicity were self-reported by youth. Self-reported weights were categorized into percentiles based on Body Mass Index (BMI) as defined from NHANES II data (NCHS,1987). BMI 31 [wt(kg)/ht?Cm)] is many times used as an indicator of body fatness and can be determined easily by heights and weights. Participants who were 515th percentile were classified as low weight, 215th percentile and 585th percentile were classified as average weight. Youth who were >85th percentile were classified as overweight. Proceduros Before interviewing began, the project was approved by the University Committee on Research Involving Human Subjects (See Appendix B). Consent forms were signed by participants and by parents prior to interviews or focus groups. Two different consent forms were used. One consent form was used for participants interviewed at the Michigan State University's Clinical Center and the other consent form was used for all other interviews (See Appendix C). Following recommended procedures for the conduct of focus groups (Krueger, 1988), introductions of the interviewer and assistant were made at the beginning of the interviews and focus groups, along with a brief description of the project. Participants were asked to give their own opinion and told there were no right or wrong answers to the questions. An assistant, usually one of the researchers or an undergraduate Dietetic student, audiotaped the interview and kept nOtes about what was said at the focus group meetings. Participants completed the demographic profile before the interview began (see Development of Instruments 32 section and Appendix D). Participants were told their answers would be audiotaped on a tape recorder but would not be associated with their name or demographic profile. Twenty-five individual interviews and 13 focus groups were conducted (66 participants). All interviews and focus groups were conducted in a private place where others could not overhear and lasted approximately 30-60 minutes. Thirteen individual interviews were conducted in the homes of the participants; two in the Nutrition Assessment Lab at Michigan State University; one in a private room at Kinawa Middle School in Okemos, MI; two at the Clinical Center at MSU; and four in classrooms at The Black Child and Family Institute. One focus group was conducted in the home of one of the participants; seven in the MSU residence halls for 4- H Exploration Days; and four in classrooms at The Black Child and Family Institute. Using a word processor and headphones, one of the researchers (Kwantes) and a paid assistant transcribed each audiotaped interview onto pages with 4-inch right margins. Wide margins allowed the researchers to note key phrases and ideas directly onto the typed interviews. Interviews were evaluated to clarify questions and to develop common themes in the answers of the participants in preparation for entry of data into the Ethnograph Software, Version 3 (Seidel et al., 1990) (See Analysis section). 33 e o ent ns s Qomograohic and Body Image Questionnaire The demographic profile instrument requested information about gender, race and self-reported height and weight as was described earlier under Recruitment and Description of Subjects. The demographic profile instrument can be found in Appendix D. Information on the demographic profile about parent's occupation and education level was also asked to provide information about socioeconomic status. To learn about youth who had overweight friends, subjects were asked for the number of close friends they had and how many of them were overweight. Because perceptual criteria of weight and body shape has been demonstrated to be more relevant to teen's weight concerns than actual body weight measurements (LeBow, 1989; Baum, 1984), questions about body image were included. Subjects viewed six male and six female silhouettes of the same height, but of variable weights, and identified the figure they thought best described their father, mother, siblings, a close friend and themselves (Dwyer, 1969). Socioeconomic status, body image information and body perceptions of others were not used in this research project, but may be helpful in future work with these data. 34 1W The interview questions were an integral part of developing a theory of the process of stigmatization of obesity in youth. Table 3.1 shows a matrix of the types of questions, the groups of participants and the instruments used to generate theory (See section on Development/Use of Grounded Theory in literature review and Generating Theory in methods). An initial list of 10-15 questions (Question Set #1) were developed from: 1) published assumptions held about stigma of overweight adolescents (See literature review on stigma of obesity); and 2) the initial objectives for this study (See Appendix B). These questions were then tested with the first group of subjects (Group 1). Table 3.1. Matrix of type of interview questions, subjects and instruments used to generate theory for stigmatization of obesity in youth. Part 1 Part 2 Part 3 Type of broad refined changed questions questions questions questions for overweight participants Subjects Group 1 Group 2 Group 3 Instrument Question Question Question Set Used Set #1 Set #2 #3 Following this first round of subjects, the researchers evaluated participant responses and refined the questions into Question Set #2 (Table 3.2). Responses from the first 35 Table 3.2. Question Set #2. Refined interview questions for how obesity is stigmatized in youth. 10. How would you define the word fat? obese? overweight? What word would you use to describe a friend who weighs much more than what you think they should? Would you use the same or different words for someone you did not know? What are overweight kids your age like? What is their personality like? What do overweight kids do on weekends and after school? Are there any ways they are different from kids who are not overweight? Can overweight kids your age lose weight if they really want? How can they? Why can't they? Some people make fun of kids who are overweight. Why do you think they do that? What are some examples you have heard or seen? Is being overweight worse for boys or girls? Do any boys want to be overweight? How many of you have friends who are heavier than what they should be? Are they different or the same as other heavy kids? What kinds of groups do you have in your school (e.g, preppie, nerd, jock)? Are there any fat kids in these groups? Why or why not? How does a fat kid get popular? What do you think are disadvantages of being overweight? Are there any advantages? Can you think of anything else that might help us learn about overweight kids your age? 36 set of subjects highlighted the need to develop a brief questionnaire for demographic and body image information as explained in the previous section (See Appendix D). Because Question Sets #1 and #2 were asked of primarily average weight youth about overweight youth, a third set of questions (Question Set #3) were developed to be used specifically with overweight adolescents. These questions were similar to Question Sets #1 and #2, but rephrased to be less threatening for overweight youth. (See Appendix B). As explained in the section Development of Instruments, Question Sets #1 and #2 were used as guides to develop a theory about stigmatization. Therefore, not all questions were asked in the exact same manner with each participant. Some questions may have been asked of the first few participants and focus groups and then not asked of the following participants because the same answer was given several times previously and no new information was obtained. Other questions were added through the interviewing process. For example, by asking the question, "How do other kids treat kids who are overweight?", one of the pilot interviewees responded that it depended on the popularity of the overweight youth. The interviewer then asked, "How does an overweight kid get popular?". This question was not asked with the previous five interviews, but was incorporated into later ones, because of its relevance to the study. 37 ADSLYSiS The qualitative data of this project were analyzed by the gonoraor comparariye mothod (Glaser and Strauss, 1967). According to Glaser and Strauss, this method of joint coding and analysis is to generate theory more systematically...by using explicit coding and analytic procedures.... It is designed to aid the analyst... in generating a theory that is integrated, consistent, plausible, close to the data-and at the same time is in a form clear enough to be readily, if only partially, operationalized for testing in quantitative research. (p.102-103) Analysis of qualitative data requires the generation of a list of codewords which clearly and completely represent the data (Miles, 1984; Stewart et al., in press). Codewords categorize qualitative data and serve as "retrieval and organizing devices" for clustering the data in preparation for analysis and interpretation ( Miles and Huberman, 1984: Stewart et al., in press). Qoileotion of Categories A Following recommended procedures, each transcript was reviewed and each statement of the participants was coded under appropriate categories. Categories were developed and refined (Figure 3.0) when the three researchers (Kallen, Kwantes, Hoerr) met to discuss the answers of participants from the transcripts. Categories developed as the reading of the transcription progressed (Appendix F). According to Fern (1982), a category must express a thought in a relevant, unique and meaningful way. For example, category 38 "I" in Appendix F includes the answers participants gave for their definition of "overweight"; two other categories, "II" and "III", were developed for definitions of "fat" and "obese". Subcategories were also developed to analyze categories more specifically. For example, when the respondents gave answers for their definition about overweight that related to "appearance", the statement was coded as "I", for overweight defined, and "ID", for overweight defined related to "appearance". After each transcript was coded with agreement of all the researchers, the codes and transcript were entered into Tho_firhoogrooo program, Version 3 (Seidel et al., 1990) by one researcher (Kwantes) in order to examine interviews and focus groups according to categories. An example of a coded interview obtained from Ethnograph software can be found in Appendix G. The Ethnograph program listed coded statements of the interview or focus group according to each code the researcher specified (Appendix H). For example, if responses about overweight friends was needed, the researcher would type in "IV", the code given for "overweight friends". The Ethnograph program would select . and list statements of all interviews specifically coded as "IV". Ethnograph permits statements to have more than one code, if necessary. For example, descriptions participants gave of their overweight friend's personality or behavior 39 was coded as "IV" and "IV.B.". Therefore, responses of participants could have been coded in several places, and, in some cases, different categories. The Ethnograph software was used to examine coded responses by category for the researcher (Kwantes) to determine common responses, to separate responses, by gender if needed, and to theorize how each category related to other categories and to the total process of stigmatization of overweight youth. Colieotion of Categories 8 The collection of Categories B was developed after the overweight participants (n=10) were interviewed (Appendix I), but Collection and development were similar to the collection of Categories A. Categories B needed to be separate from the first collection (Categories A) to compare responses of overweight youth to responses of the average weight'youth. The output for both collections of categories (A and B) was examined in order to: 1) generate theory of stigmatization of overweight youth; 2) develop a conceptual model regarding this process of stigmatization; and 3) aid in developing a quantitative tool to measure stigmatization of obesity. 40 me of e once tn 1 e and est on a e The conceptual model was developed after the interviews were coded and a better understanding of the process of stigmatization was obtained from the results (See Results and Discussion). The researcher (Kwantes) drafted a conceptual model initially, and then finalized through comments from the other researchers (Hoerr and Kallen). The questionnaire was developed in a similar manner as the conceptual model (See Results and Discussion). Constructs were developed from participants' answers and a draft was written using guidelines from Henerson and coworkers (1987). Chapter IV RESULTS AND DISCUSSION The results of this research project are discussed in terms of group findings, not differentiating between age, race or gender. Subjects provided demographic information and there were no notable differences between age, race and gender related to the major findings of this study. Organization of results differs from the order questions were asked (See Generating Theory in Methods and Figure 3.0). Results are organized to demonstrate the development of a theoretical process of how an adolescent stigmatizes or does not stigmatize an overweight peer (Table 4.0). First, how adolescents obtain information about weight is reviewed. The answers youth gave about weight and their observations about overweight peers, sets a foundation for how they define concepts such as "overweight", "fat" and "obese". Secondly, these concepts are discussed to understand how adolescents stigmatize or do not stigmatize obese peers. Finally, the exceptions to stigmatizing an overweight peer are discussed. Following these three steps, 41 42 the process of stigmatization is developed and more easily understood than before this project was conducted. Table 4.0. Outline of results and discussion. A. Sources of adolescents' preconceived ideas about weight. 1. Media a. Overweight is worse for girls 2. Observing others a. Teasing b. Teachers 3. Noticing disadvantages of overweight 4. Overweight causes and weight loss B. The adolescent's definition of weight. 1. Definitions a. Fat b. Overweight c. Obese 2. Stigmatization C. Adolescents' exceptions to stigmatization of obesity. 1. Big Friends vs. Big Strangers 2. Popular overweight youth 3. Advantages to being overweight during adolescence 4. Other considerations D. Conceptual model. E. Questionnaire. F. Limitations and Strengths. Each of the sections in Table 4.0 will first include results from the first two groups of respondents (n=53), called "average weight responses". Responses from the overweight subjects (n=10) follows those of the average weight and is called "overweight responses". When quotes of participants are used, "I" indicates the interviewer and 43 "R", the respondent. Participants' quotes are preceded by alphanumeric descriptors and transcript line numbers in parenthesis. A. on ces of ado sce ts' econceived ideas about woighr Media Adolescence is a time in life when influences outside the home become very important for social development (Kelly and Hanson, 1987). One of the ways adolescents are influenced is through the media. Advertising on television or in magazines tells adolescents each day what is "in", what is "out", what one should look like to be important and successful and how to make it in the world (Richins, 1991). Green (1990) and Story (1990) suggest that television portrays an unrealistic picture for the adolescent of what the world is like. Youth watching television may also obtain an unrealistic view of body types which could in turn affect their own body image (Dietz, 1990). Avorggo yoight responses Average weight respondents were asked what type of people they see on television shows and commercials, underweight, average weight or overweight. Most respondents said they saw only underweight or average weight people, because these were the preferred body types to sell products. A few respondents said they saw all body types on television. 44 Qyoryoight responses Most overweight respondents agreed that the media has only underweight or average weight people on television. Their responses were similar to those of the average weight youth. OVWTG (842-869) I: When you watch television, what types of people do they have? Do they have underweight, average weight, or overweight people? R: Average. Average, oh, just because that's what fits the general idea of what they see on television. They don't want to see huge people walking around on television. I: Why do you think they don't? R: Mostly because of the attitude of the public. I mean I don't believe I've ever seen a show where they wanted to have overweight people. I mean the attitude of the public seems to be if it's overweight, it better be a comedy show. I: Why do you think that is? R: I have absolutely no idea except that is how their parents brought them up. The answers obtained from all respondents suggest that the media shows mostly average weight or underweight people, because this body type sells advertised items and is most preferred in society. Therefore, overweight body types are not acceptable because society does not like to watch them on television or see them in magazines. Also, the answers youth gave about who they liked or admired on television were not only people who were young and thin, but also attractive. Such responses may suggest that being thin is 45 necessary to be physically attractive, but not necessarily sufficient. ovoryoigpt gorse for girls The effect the media and advertising have on adolescents may be more important for females than males. The media portrays thinner standards for women than men (Silverstein et al., 1986). The message of "girls are suppose to be thin" seems to be getting through to adolescent females. Worsley (1981) found that overweight is physically unattractive among girls. Girls who are early maturers and may have more fat deposition at that time than their female peers, are also Viewed as fat rather than mature (Peterson and Brooks-Gunn, 1988). Richards and colleagues (1990) found adolescent girls in the 8th and 9th grades were more Concerned about their weight and eating habits than boys. As a result of this preoccupation, girls spent more time alone and less time with friends or in social activities than boys. e a wei t res onses Respondents agreed it is definitely much worse for girls to be overweight than it is for boys to be overweight (Table 4.1). Almost all respondents said it was worse for girls, because they are "supposed to be thin". Society demands a thin female. Appearance is very important for females and "looking good" means being thin (Jackson, 1992). 46 INTERl (358-363) R: ...most people like to see the girls in bikinis, girls should be thin...so probably worse for them because they're suppose to be, they're expected to live up to this reputation. FOCGRMAY (444-445) R: Girls try to look better than boys. Boys just don't care... FCSlJU23 (401-402) R: There's more pressure for girls to be skinny. 4HGROURB (244-247) R: Cause girls they like to do stuff and they like to wear tight clothes and it don't look right if they're bulging in their pants. Many also said that overweight girls would have a more difficult time getting a date or being asked to a dance than an overweight boy would have. Table 4.1. Reasons given by respondents for why overweight is worse for girls or for boys'. Worse for Reasons Boys Girls Number of mentions Appearance/reputation 0 11 More societal pressure 0 11 Others 1 3 ‘ Question was not asked of all participants. 47 deryoight rospopsos Overweight and average weight respondents answered similarly. Eight participants said it was worse for girls, mainly because they are "suppose to be thin" or they cannot get a boyfriend. One participant said it was the same for boys and girls, but there are more girls overweight. One youth said overweight was worse for boys, because not as many are overweight, so when boys are overweight, it's worse than for girls. It seems clear that being an overweight female is worse than being an overweight male. Ironically, this happens when normal physiological changes which increase fat deposition are occurring in female adolescents (Dwyer, 1973). Gortmaker and coworkers (1993) reported overweight in female adolescents may also be an important determinant of socioeconomic status. Overweight women were more likely to be poor and unmarried than other women in the Gortmaker study. They hypothesized a reason for these findings might be a society stigmatizing and discriminating the obese. Michael Levine and colleagues suggest that the "drive for thinness" is especially a concern for middle school girls who receive daily messages from family, peers and the media about the importance of being thin (personal communication). 48 Teasing Another way adolescents obtain information about acceptable body weights is by observing behavior of peers in and around a school setting. The observed encounters of how overweight youth act and are treated is influential in adolescents' ideas about weight. The most common observation involving an overweight peer appeared to be teasing and activities overweight youth could not perform well compared to average weight or underweight youth. Teasing influences how youth negatively perceive overweight and it is one way overweight youth are stigmatized. Thus, teasing is included in both sections, A and B, in the outline of results and discussion (Table 4.0), but is discussed here under A. v a e we es s s How overweight youth are treated was asked of all respondents (Table 4.2). Boys, popular youth and skinny people were among the most frequently mentioned youth who teased overweight adolescents. Youth teased overweight peers either behind their back or right to their face. The times teasing occurred was during lunch, when others could observe the overweight youth eating, or during a gym class, where everyone had to perform physically. If the overweight youth could not do the activity or "looked funny" doing the activity, he or she would be teased. The following quotes suggest some reasons why overweight youth get teased. 49 Table 4.2. Reasons given by youth for who teases, what teasers do, and why youth tease overweight youth“. Boys Girls Number of mentions "Who teases" Mean/Angry people 2 4 Youth in lunch room/gym class 0 3 Boys/"jocks" 3 10 Skinny people 2 3 Popular youth/snobs 0 4 ”What teasers do" Make fun behind back 5 3 Name calling to face/put downs 5 18 Miscb 1 1 "Why youth tease" Overweight kid is "different" (not in shape,loners,don't keep clean, run funny, eat funny) 5 14 Teasers are mean/get attention 4 20 Overweight youth easy targets (Cry,feel bad, shy, get angry) 1 8 No reason/Nothing else to do 0 3 ° Not all participants were asked this question in the same manner. b Miscellaneous responses indicated that teasing depended on how the overweight youth responded. If overweight youth acted as if they did not care, teasers would stop teasing. 50 INTER3 (339-340) R: Because people think they (overweight youth) are different, some kind of bias. INTER6 (138-144) R: Well, I think that people when they tease overweight people they are just trying to do it to make them feel bad, but when, and they know they made them feel bad so they sort of stop, they stop after a while. FOCGRMAY (371-374) R:...they(teasers) might tease them (overweight youth) because they think they can probably can do more things than they (overweight youth) can, like they can run faster and stuff. Overyeignt responses Overweight respondents said that teasing happens more often in middle school than in high school. They said mainly the boys do the teasing and the fatter someone looks, the more they get teased. Some youth explained what happens during the teasing. Comments were things like, "they (teasers) talk about me", "they laugh at me", and "they gang up and jump on me". Feelings and responses to teasing were consistent among the 10 respondents. The best way to deal with the teasing was to ignore it, even though it made the overweight youth feel terribly sad, angry and not "worth anything". .OVWTZ (333-340) - R: ...like if they are teasing me I just go over and talk to my friend, "Hi, how are you doing?" Then they're sitting there talking about you and everybody's laughin because they're, they're talking about you and you're not even payin them any attention. (591-615) I: How do you think you got to have that attitude of "well, I don't care and it's not gonna bother me"...? 51 R: Probably because when I was in the 2nd grade and used to cry every time somebody said one little thing to me then I learned you can't just do that.... Because they thought problems, there was problems in my house because I kept cryin, but it wasn't, but I kept on tellin them "No", but everybody, they wouldn't listen to me. OVWT3 (748-758) R: I tried last summer and I lost quite a bit of weight but then I gained it back because I had tried to loose weight and so um, the more I would eat because food consoles, it's like a friend. The more you get teased, the more you eat, the more you eat, the more you get teased and the more you teased, the more you want to eat, it's a vicious cycle. (782-791) R: Well, I just let it (teasing) roll of my shoulders until it got so out of hand that I just, every night I came home and I started to cry usually. I: Did that last for a long period of time? R: Most of sixth grade. 0vwr4 (325-328) R: ...you just have to get your head on straight and see that it's (teasing) their problem not yours. (555-563) I: Well, what would you do then (middle school) and then we can talk about what you do now (high school), because it seems like you have changed. R: What I would do then is look down on myself which would cause me to eat and then I look down on myself and it's like a cycle. (593-509) I: A lot of people don't see that inside do they? R: No. Because they cover it up. You cover it up with being overweight. I: Tell me more about that, it's interesting. R: You don't want people to see that you are hurting or that you don't, that you, um, that you don't want to be around people. So you make yourself look ugly and people go away from you and then you can be alone. 52 OVWT6 (939-956) I: What would you tell a group of kids who maybe were fed up like you? How to handle teasing and the situation they're in? R: Don't try it out in public and go home, get mad and get over it because it's going to happen throughout your life. I: So just deal with it? R: Yea. I: How do you deal with something like that? R: Mostly crying myself to sleep. OVWT9 (610-618) R: Well, you probably say something bad back to them (teasers) or else it will just getting worse, but you should tell them that it hurts your feeling when you do that and it really doesn't help you as a person to get better with your weight. A person doesn't like going to school every day just to get teased. Four overweight respondents said they do not ever tease anyone, such as skinny people or people heavier than them. They did not tease others, because they knew how a teased person felt and did not want to do that to anyone. Two respondents said they acted as "bullies" or "teasers" in a few occasions. Why teasers tease overweight peers was another area of investigation. Participants had similar responses as the average weight responses, that overweight youth are seen as "different". OVWTl (240-248) R: ...I'm overweight and they're not, then they would talk about me. I: Why do you think that is? 53 R: I don't know. They probably think that we're different than other people, because we're bigger and they're smaller. OVWT2 (282-294) R: Because they're (teasers), they're lookin at somebody who's different and they are like wondering how it is to be different, I guess, I don't know they just do it cause they want to. Cause I... they say when people tease you and stuff they're doing this because, my mom said, I think my mom said they're doing this cause they have like problems maybe and they're like... make fun of you because they wanna feel better bout themselves. OVWT4 (279-286) R: ...Everyone is insecure (in middle school) , they don't know where they belong, so they decide, well, you know, I'll pick on someone else. OVWTlO (212-214) R: Well, I guess some of them just do it to get attention. That's the only reason. Teasing overweight youth might result from feelings of insecurity in the teasers leading them to making themselves feel more secure by putting others down. The respondents seemed to agree with this. Lerner (1985) suggested that a negative reaction from peers results from how well the characteristics of the adolescent "fits the demands" of the peers. In some situations teasing can most likely be stopped by the one getting teased. For example, if one gets teased for wearing odd looking shoes, not wearing those shoes and choosing more acceptable shoes would stop the teasing. Overweight youth, however, cannot easily change their body to a more aCceptable body type, if at all, and, therefore, become easy and continuous targets of teasing. Ignoring the teasing was a popular response from youth 54 about how to deal with the teaser. This response, however, might not be appropriate for all situations and for all stigmatized overweight youth, as will be discussed later in the sections on approaching strangers and meeting friends. Athlerics and teasing An important concept that resulted from questions about teasing was the importance placed on sports and physical activity at this age. Physical education classes were seen as a place where teasing occurred quite often for overweight youth. Activities that included running were episodes where overweight youth were seen as slow and embarrassed to compete with other youth. Physical education classes are important for adolescents by promoting healthy lifestyles. However, these classes need to reduce potentially stigmatizing events, such as time for a mile run, in order for overweight youth to become active in school. Because we live in a competitive society where sports and athletics are important, it is equally important to show adolescents that youth who may not be able to compete well physically, are still valuable to society. T t en rom teache s Along with observing other youth during school time during the day, youth also observe how adults, specifically teachers, treated overweight youth. 55 w n e Not all of the youth were asked the question about how teachers treat overweight youth. Of those who were asked, all said teachers showed no special treatment to the overweight youth. Ov rwe t s o ses Six of the overweight respondents said that teachers did not treat them differently. In fact, two of them went on to say their teachers were good friends and someone they could talk to who would not tease them. Three of the respondents, however, did mention some teachers would ignore the teasing the overweight youth was receiving from peers. There also seemed to be a dislike of gym teachers, apparently because these teachers chose them last for teams and again ignored the teasing. One respondent said that it was embarrassing to be given special privileges such as not having to run as far or as much as the others in gym class, because she was teased even more for something the teacher thought would be helpful for her. These responses may suggest that teachers, especially gym teachers may stigmatize overweight youth, without realizing, in two ways. First, teachers who try and ignore the teasing of overweight youth by others, thinking ignoring the teasing may diffuse the situation, actually may create more stigmatization because youth know they can "get away with teasing" in class. Secondly, teachers choosing 56 overweight youth last for teams or allowing special privileges such as sitting out during an event (thinking that this will reduce the teasing), may be sending stigmatizing messages to youth about overweight. How teachers treat overweight youth and the effect their treatment may have on adolescents, is a topic that needs further investigation. Disadvantages and consegpences of being overweight Another way adolescents obtain information about weight is noticing the disadvantages or consequences in society associated with being overweight. These disadvantages relate to previous observations from these respondents regarding the media and teasing. For example, a disadvantage to being overweight may be not looking good according to societal expectations. These observations depend on how the media and society present desirable appearance. Average weight responses Respondents said appearance was a disadvantage to being overweight (Table 4.3). Many said a major disadvantage of being overweight is feeling sad and ashamed of their bodies because of the teasing. Some examples follow of responses to the questions, "How do you think overweight youth feel about their weight?" and "What are the disadvantages of being overweight?" 57 INTER2 (352-355) R: ...real embarrassed but some of them that don't have many friends are probably real embarrassed about it and wish they could be thin... INTER6 (232-239) R: Some, some people do because they think that, I guess it's just that they act kinda depressed because they don't have a lot of friends or else they are afraid their weight will stand in the way of what they are doing or something. INTER9 (493-498 and 524-526) R: Most kids don't like it. I: Why do you think that is? R: Because they want to be like everybody else....they want to fit in, or something, and they don't want to stick out of the crowd. FOCGRMAY (478-480) R: But some people they don't like to be overweight because they get talked about... BCFI3DF (521-529) R: You know when you are obese you don't see yourself as good. You like, people keep talking about you and telling you like ya, you're fat and ugly and stuff. When you look in the mirror that's what you going to see. Then you start puttin yourself down and stop having contact with the rest of the world... Others responded that overweight youth could not do the same activities as average weight youth. These activities, as mentioned previously, are situations where overweight youth are likely to be teased. BCFI3DF (164-168) R: We had this one on our kickball team, but he real good but he can't run to the bases, and um, everybody teased him and he was always sad. INTERB (53-57) R: ...they can't do things like they can and like they can't play sports as good because they can't run as fast or something like that. 58 INTER7 (631-634) R: And, um like they might not be able to do things as well as other kids if they're overweight. Table 4.3. Disadvantages and consequences of being overweight given by boys and girls“. Boys Girls (n=17) (n=49) Number of mentions Clothes too tight/small sizes 1 11 Ashamed/Sad/Low self-esteem 5 22 No/Few friends/Can't get a date 8 11 Get teased/talked about 5 11 Can't do things as well as others (run, sports) 5 13 Misc 2 7 ‘ Question was asked of all participants (n=63). Qveryeight responsos Overweight respondents answered similarly to average weight respondents in this category. Most answers related to overweight youth getting teased more than nonoverweight youth, because they could not do activities, such as running, as well as other youth. One of the respondents said that a disadvantage was "you miss out on life" because of isolation and loneliness due to embarrassment to go out with peers. Missing out on life, not able to compete as well as others and not looking attractive were responses associated with overweight. All of these concepts are essential for adolescents' social development and understanding where they 59 "fit in" in the world (Lerner,1985). .Therefore, it is important to understand that overweight youth are faced with being "different" in these areas before they even have a chance to develop who they are and what makes them special and unique and important to society. use of ov t and w t oss A final concept related to how adolescents obtain information about weight is their ideas of the causes of overweight and whether weight loss can be achieved. Adolescents may learn information about weight through what they observe through weight loss program advertisements and magazine articles related to weight. Weight loss programs and advertisements show how happy people are, who lose weight, and how unhappy and unhealthy overweight people were before they lost weight. These examples again promote a thin physique, not only to be acceptable or to compete in athletics, but also to be happy and healthy. Average weighr responses Respondents thought overweight youth become overweight because they sat around too much and did not exercise (Table 4.4). Youth did not perceive overweight peers as exercising and eating healthy. In fact, almost without exception, respondents thought if the overweight peers really wanted to lose weight, they could. A few of them thought they could not, mainly because they were from a family of overweight 60 people. Almost all-thought overweight youth could lose weight with diet, either eating better or less, and by exercise. INTER? (365-370) R: Yeah, but, um if they just watch, like if they ate just as much but it was just good things like vegetables and good stuff, um, they could probably do it and it wouldn't really be on a diet. INTER8 (444-446) R: Well some can go on diets like don't eat quite as much food or not as fattening food... FCSZJU23 (380-385) R: Well they could exercise more and they could, they shouldn't sit around like a couch potato and just pig out. And change their snacks like instead of chips like carrots or something. JUZSFGI (387-388) R: By exercising and eat vegetables and stop eating junk food. Table 4.4. Reasons given by boys and girls for causes of overweight and ways to lose weight for overweight peers. Boys Girls Number of mentions "Causes" Sit around("couch potato") 5 15 Eat (Too much, not balanced) 9 19 Familial 1 5 Misc 1 4 "How to lose" Exercise/Sports/More active 8 23 Eat less/diet/eat better 11 23 Through friends encouragement 0 2 61 These responses of adolescents are not surprising because adults, even in the health profession, have had similar responses (Wiese et al., 1992). The responses are important determinants, however, of how overweight youth are viewed. Adolescents simply believe that overweight youth are overweight because of their eating habits and lack of exercise, and if overweight youth really wanted to be an acceptable weight, they could. Interestingly, adolescents state all the disadvantages of being overweight, and yet they say overweight peers can get out of their situation, if they really wanted to do so. Adolescents appear to be unaware of the irony of believing that overweight peers onoose to stay in an environment that is cruel and one that no adolescent would want to be in. Many studies show that weight loss programs are not effective and have even been called into question as far as efficacy (Wooley and Garner, 1991), and yet adults continue to allow youth to hold opinions that weight loss is achievable by everyone if they just tried hard enough. Meanwhile, overweight adolescents everyday are seen as unworthy and unacceptable, because they do not live up to a desirable weight "standard" that even health professionals are unsure that everyone can achieve. 62 Ove ' t s o ses As a reflection of what the average youth thought overweight youth did after school or on weekends, overweight youth were asked what rnoy did during these times. Average weight youth reported overweight youth sat around and "pigged out". Overweight respondents reported being active after school, in a school activity or hobby. Four responded that they liked to watch television and snack after school. These were the same types of activities that average weight youth liked to do, except overweight youth were viewed as "lazy" for the same behavior. Three of the overweight respondents thought that overweight was due to how a person eats, either too much or the wrong types of food. These respondents, along with others, also said overweight causes are mostly genetic, related to emotional problems or problems at home which cause a person to eat when not hungry. One overweight youth said she gained weight because she was "lazy" and less active than in the past. These answers are somewhat similar to the average weight, but seem to stress more the genetic component to weight gain and less the individual's lifestyle. One of the overweight participants explained that most youth do not understand why weight gain occurs, they just see it as "different". OVWT6 (639-661) R: It (weight loss) just depends on the person because their metabolism changes. 63 I: Do you think that most people understand that? R: Not a chance. I: So you're saying, if it's genetics, than it's not really... R: They don't realize it. All they realize is that you are bigger than the other kids and they think it's funny, weird, strange, whatever you want to call it. As with the average weight responses, overweight participants answered questions whether overweight people could lose weight if they really wanted to, how they might lose weight, self weight management techniques and weight management techniques of others. Four participants said a person could lose weight, if that person really wanted to lose. Four of the youth said it depended on the person and the situation, such as genetic factors or emotional problems that would play against the weight loss and keep the person overweight. One participant said a person could not lose weight, if he or she really wanted to lose.' . The main responses to how a person loses weight were similar to the average weight responses. -Youth said weight loss could be achieved by increasing exercise and limiting fat and calories in foods eaten. One of the youth said all that is needed to lose weight is a positive attitude. Two of the respondents talked about their own weight management techniques which included "nothing sweet" to eat, eat more fruit and exercise more than in the past. One of these youth said that support from her mother and friends was 64 helpful for weight management. A few of the respondents said they saw peers trying to lose weight through starvation diets or diet plans, decreasing food and becoming more active such as joining a sports team. It is interesting that the overweight youth stressed that weight is not always under the control of the individual, but seemed to agree with the average weight respondents that weight loss could be achieved by everyone. Further investigation into this area may lead to more understanding of how youth view weight loss and who is responsible for it. B. Adolesoents' definitions of weight. " ve ei h " " t" and "obese" Definitions of concepts or words to describe a peer whose weight is seen as unacceptably high will come from the information they have about weight. The information about weight was previously discussed. How a person is labelled, as will be discussed in the next section, will be relevant to the process of stigmatization. Avarage weight responses Common statements given by participants about the concept of "overweight" were related to appearance (Table 4.5). Youth stated that a person was considered overweight, if they looked bigger in size than others around them. 65 Examples included: INTER6 (7-9) R: Well, I guess it means that you are just a little larger than people that are your own age. INTER? (65-68) R: (You can) just tell by looking at her even if she has loose clothes on because she's just bigger than the other kids and heavier. JU25FGl (103-107) I: What do you think the word overweight means? R Not the normal size as average people. TAMARA (5-7) R: Um, over the weight that the doctor might say you're supposed to be. Some respondents described the word "overweight" in terms of actions of a person they thought to be overweight. For example, overweight meant someone who eats a lot of food and does not exercise or someone who gets teased by others a lot. Many youth stated that overweight was the same as the word "fat", but "overweight" was a nicer word to use when describing someone else. When participants were asked to describe the concept of "fat", appearance was again one of the main ways to describe the word (Table 4.5). The examples given, however, were more derogatory and negative than those used for "overweight". Illustrations of this follow. 66 Table 4.5. Concepts used by boys and girls to define the word "overweight", "fat", and "obese".' Boys Girls "Overweight" Number of mentions Appearance 8 24 Same as "fat" 2 10 Nicer word 1 4 Eat more/Exercise little 1 4 Misc 1 2 "Fat" Negative descriptors 1 4 Appearance 3 22 Same as overweight 2 3 Misc 2 3 "Obese" Don't use/Never heard before 1 10 Huge/Big 2 6 Misc 1 6 ‘ Question asked of all participants (n=53) INTER 6 (43-44) R: (When) people say fat you think someone is really big. JU25FGl (4-22) I: How do you define the word fat? Rs: 5: Bloated....Rolls on their stomach. 4: When you got a lot of meat on your body. I: What does that mean? Can you be a little bit more specific?" R: 4: A lot of skin 67 INTERl (20-26) R: Fat, usually when someone says fat they're either in a fight with that person or that person is really really big and they don't know them. INTER9 (92-93) R: ("Fat" is used) like when you're talking about them like cutting them down. The word "obese" was not as easily defined as the other two words (Table 4.5). Many respondents did not know what the word meant, had never heard it before, or thought it was not used much, because it was a "scientific term". deryeignt responseo Respondents answered similarly as average weight respondents. Overweight was described as a nicer word to use and defined as someone who weighs more than what the average weight-for-height charts show one should weigh. OVWTl (41-45) R: ...say when you are thirteen and you're supposed to weigh 100 pounds and you weigh 190 or something. OVWT3 (265-270) R: Well, technically it means that you weigh more than what the usual is for your age and height. But like the other kids see it like if you have a little bit of a stomach or something like that. OVWT6 (119-126) R: In my opinion when people say overweight, they are just trying to make it easier on the person who is listening to it than saying fat because they mean the same thing, it's just when you say overweight it doesn't sound as bad as just plain out fat. OVWT7 (59-66) R: I think, cause I don't really believe in the charts where it says you should be in between this weight because I think it's different for every person, but I think that overweight means that it begins to affect your health, or that it could affect your health. 68 Respondents agreed that "fat" was about the same as "overweight", but used in a negative manner. Generally, respondents had not heard of or did not know how to define the word "obese". From the answers given by all, the concept of "fat" appears to be a stigmatizing word, meant as a put down or used in a negative way. "Fat", "lazy", "different" and "mean" were words used to describe a stigmatized overweight peer and have not changed in the past two decades (Allon, 1979; LeBow, 1988; Sobal, 1984). Dwyer (1973) and Allon (1979) have suggested that consequences of being labeled "fat" or "different" during adolescence can have serious detrimental effects on social interactions with peers, as well as possible problems achieving weight management goals. Tobias and Gordon (1980) in their discussion of Laslett and Warren's (1975) study point out that once someone is labeled different, even if weight management goals are achieved, these people still see themselves as different, because the fear of rejection in the past has been overwhelmingly painful. Another reason for still seeing themselves as different, even though their physical bodies have become acceptable, is the time of life during which teasing and negative messages from others occurs. Adolescence is a time when negative messages about the body affect the person's body image or views of the "self" which then carry into adulthood (Stunkard and Burt, 69 1967). The potential for serious harm to the "self" makes exemptions of stigmatization a hopeful prospect, discussed in the following section. . ons at' t'on s ' 'en ' s a ers During the interviewing, it became clear that not all overweight youth were stigmatized. By probing for nonstigmatization of overweight youth, the process of stigmatization was clarified somewhat. Also, ideas to help overweight youth cope and deal with the stigmatization of obesity were developed. Youth have different ways to describe a "big friend" versus a "big stranger" (Table 4.6). Strangers were defined by the interviewer for the subjects as "people their own age whom they had seen but had never met" or someone not considered a good friend". As previously presented, "overweight" was used mostly for big friends and "fat" was most likely used to describe a big stranger. Talking about strangers, respondents said: BCFIBDF (143-147) 3: If you talking about a stranger you would use fat but if you were talking about a friend you wouldn't say fat because that is sort of like a mean word. JU25FGl (148-153) 1: Fat seems like a rude word. 2: I would say she ain't fat and she ain't overweight, she's heavy set. That's what my mother told me to say. 70 Table 4.6. Words used to describe friends and strangers whose weight for height is greater than socially accepted standards“. Number of mentions for Words Friend Stranger Descriptors Fat, fatty, "pig" 6 16 Heavy set 3 1 Overweight 14 2 Obese 4 0 Chubby,Large,Big,Chunky 4 4 Plump 1 0 Stomach too big 0 1 "What they are like" Different 1 7 Negative descriptors (Snotty, obnoxious,lazy, stupid,ugly,slob, mean) 1 24 Depressed 0 2 Nice (fun) 6 13 Sensitive (shy) 3 5 Same as other kids 7 16 “ Question asked to participants in Group 1 and Group 2 (n=53) INTER4HW (69-83) I: Would there be any times that you would use the word fat when describing someone? R: Yea I: Can you think of maybe what times you would? R: If I was mad at them. I: Why? R: Because it's, it's, fat is like describing a pig. 71 Talking about big friends, respondents said: INTER9 (277-288) I: Are any of your friends overweight? R: Yeah. I: 0k. Do you think your friend is like most overweight kids or do you think your friend is different form most overweight kids? R: Well, my friend just accepts it. He doesn't care. FCSIJU23 (574-576) 2: Well, she's really sweet and she helps me with my homework, and, I mean, we do things together. Other respondents said their friends were funny, nice and acted the same as their other friends, implying that big strangers were different from their overweight friends. The universal perception that calling someone "fat" is derogatory, and use of the term "fat" to characterize strangers, but not friends, suggests that overweight friends are not stigmatized and talked badly to or about. While overweight strangers are seen as "different, lazy and mean", and therefore are called "fat", overweight friends appeared exempt from the stereotype. These differences imply that it is very important for overweight youth to get to know their peers and become friends so they will not be seen as "fat" and lazy in a stigmatized manner. If overweight friends are exempt from the stereotype, then how might overweight youth who aro stigmatized make friends and become nonstigmatized? To probe for answers to 72 that question, average weight youth were asked how they met and became friends with their overweight peers. Some youth said they grew up with their overweight friends. INTER9 (169-174) I: How do you think an overweight kid gets to be good friends with people so they don't cut them down? R: They grew up with them or something like that. FCSIUSZ3 (602-607) I: How did you get to meet these overweight friends? R: I grew up with them. (845-861) ...It doesn't make a difference when you're older, like if you were in the same school when you were young, and you were, you might have been skinny then and you made friends with all the popular kids but you got overweight as you were, as you grew up you'd still be friends...Yeah, people usually in my school stay friends for their whole life. Others said they had things in common with their overweight peers such as they attended the same school or church, were seated at the same table in a class or had a friend in common. FCSIJU23 (559-568) R: There's one girl I know and we're really good friends and we (mumble) and we had a class together and we became really good friends. BCFIl (242-251) I: How did you get to meet them or how did they become your friends? R: Well, we were at church and it was like my first time I came up here. We just got to know each other so we said "Hi" and we just start to talk and stuff... we're like best friends. 73 HISPBYS (77-91) 2: Well I got friends with him when I was in Lincoln School because I got three years ago here, then I didn't know English, he knew a little bit and then he started helping me, that how I make friends with him. These answers from the average weight youth suggest that overweight youth have a good chance of becoming friends with others at an early age or sometimes during new situations. These situations included starting middle school, when classes and teachers are new to everyone and the overweight youth has a common situation with others. Average weight youth also seemed more open to making friends, when the overweight youth could help them with assignments. These new situations are also times, however, when overweight youth become targets of teasing, if nonoverweight youth are feeling insecure and tease to make themselves feel better. ve ht es onses Participants were asked if they had their own group of friends, what they were like, how they met them, and how their friends' responded to the participant getting teased by others because of weight. All but one participant said they had a group of friends they hung around with at school. All of the participants said their friends were thinner than they were. Friends were described as accepting of the respondent's weight, were fun, nice and shared common interests with the respondent. There were various responses to how the overweight 74 youth met their friends. Most said they met their friends at a younger age such as kindergarten, or met them in situations new to both parties, such as starting middle school with new classes and teachers. These responses were similar to those of the average weight youth. Two overweight youth said their friends stood up for them when they were teased and responded negatively toward the teaser. There was no direct question asked of every participant about this topic, and, therefore, not everyone responded or commented. Respondents were also asked to either explain how they would make friends or how they would give advice to an overweight peer about how to make friends. Respondents answered mainly in two different ways. They either were very cautious and "played it safe" when meeting new people, or they were outgoing and were the first to approach a new student in a new situation. OVWTl (288-293) R:...I would just tell them to say "Hi" once in a while, be friendly and say excuse me, just be really nice and normal, and I'm pretty sure they would make a lot of friends. OVWT3 (365-369) R: To make my friends I usually just start talking and then if we have something in common then we talk some more and eventually we get friends. 0vwr4f(107-111) R: Well, I make friends by studying people and watching their reactions to everyone else before I decide, before I even introduce myself. 75 OVWTS (280-282) (286-288) R: Well, I would tell them that they need to find kids that accept them the way they are...and they don't have to change their personality. Overweight youth listed qualities they considered important in a friendship. These included someone who is genuine, considerate, caring, sensitive, trustworthy, easy to talk to and not judgmental about appearance. Along with approaching potential friends, overweight youth discussed how they approached "strangers". One of the respondents summed up other responses in the following quote. OVWT7 (551-568) R: Probably just to be, as hard as it is, just try to be open and um definitely be yourself. Don't try to be something that you're not just to be cool, that's not that big of a deal. Just be friendly definitely even if they like come up and talk to you, don't think that the only reason they are talking to me is because they feel sorry for me. Because if they talk to you obviously there is going to be some people you don't get along with and that's fine. I would just try to tell them just to be honest with yourself and just be friendly because people are going to like you for basically for your inside. Although ideally average weight youth expected overweight youth to be more approachable than average, in order to make friends, and some overweight youth were very approachable, some overweight youth were very hesitant to approach people to make friends. When self concept and body image is developing in overweight adolescents, they may see themselves as undesirable and isolate themselves from peers (Rothblum, 1992). Some overweight adolescents in this study 76 told us that isolation was a way out of interaction with others and, therefore, the opportunities for teasing were reduced. Average weight respondents, however, saw many overweight adolescents as shy; this shyness was not a positive motivator for wanting to make friends. In these situations, it appears, the overweight youth may fall into a stigmatizing situation, because average weight youth dislike quietness or shyness or perceived it as a weakness. ow o ei ht 0 th et 0 ular Another way overweight adolescents are not stigmatized that became evident during interviewing had to do with popularity. Average weight youth said that there are some 'overweight youth who are popular, and therefore exempt to stigmatization (Table 4.7). It should be noted, however, that popularity of overweight peers was not a common occurrence, but occasionally observed. Most respondents said it is "who you know" that makes a person popular. BCFIl (205-209) I guess they, they must know people because sometimes it's like if you know this person you're popular and you know other people just like... BCFIZBY (694-696) - They know nice people then the nice people get their friends and they hang around them. INTER9 (181-184) I: How do you think they get to be popular? R: Because they know everybody. BCFI3DF (696-700) R: But some fat people is in the popular group because they know a lot of people. You know they have a lot of family members that know a lot of people. Cool people. 77 Others, especially the boys, said if overweight peers are in sports, they usually are popular. INTER3 (169-182) R: Yea, I know a popular kid who is really overweight but he is very good in most sports, he's athletic, he makes all the teams you have to try out for, stuff like (that, so, um, he is, I don't know, he's um, pretty popular, I'd say athletic... INTERB (461-466) I: Um, is your friend like most overweight kids or different from overweight kids? R: Well, they treat him pretty good because he's good at sport... Another important aspect of being popular or just being a friend is having a nice personality. FCSZJU23 (523-526) R:...and if sometimes if you're nice then you don't, people don't tease you because they like you and you're friends with them. TAMARA (229-236) I: What do the kids act like if they're popular and if they're heavy? R: Well, usually nice, like my friend she's really funny and lots of people like her. So she's not teased a lot. Finally, other examples youth gave for how an overweight peer becomes popular are having money, dressing well, being a class clown and driving a nice car. The fact that sports again came up as an important part of adolescence illustrates the uphill battle some overweight youth face because their bodies do not allow them to be as agile and quick as those with leaner physiques; nor do their self-concepts allow them to attempt sports because they 78 think they will be teased or put down. Table 4.7. Responses given from youth about how overweight youth get popular“. From boys From girls Number of mentions By knowing people/popular people 4 10 Good in sports/athletic 5 3 Be nice/good personality 0 5 Class clowns/humorous 2 3 Where live/have money/dress 0 4 Talk to peers/courage/ strength/think positive 0 5 Misc 0 4 “Question was not asked of all participants. Overwoignt responses Popularity was not as big an issue with the overweight participants as it was for those of average weight. Two of the youth said an overweight person can only get popular if he or she is good at sports. OVWT6 (961-966) R: Its just that kids think so much more of your body and how physically active you are, and what you do, how good you are. I mean the most popular kids at school are the ones that run 6 minute miles. Other said popularity was acquired by knowing popular people and hanging around them. Because adolescents want to fit in and be accepted among their peers, becoming accepted or popular is an important aspect of their development. Of the many 79 responses given to how to become popular, the area of sports or athletics deserves further investigation. Boys on football teams who were considered overweight were not stigmatized, because of being on a team and needing that body type for their sport. Boys seem to want to be heavier in weight, because it is related to dominance (Dwyer, 1969). Being an athlete is a sign of high status (Goldberg and Chandler, 1989; Thirer and Wright, 1985). Buhrmann and Jarvis (1971) showed that female athletes in high school hold a higher status than non-athletic females, but did not look at body weights of the athletes and the relationship to their status. novanrages or being overweight. Average weight responses Excellence in sports was a frequent answer to popularity and one advantage for overweight for boys (Table 4.8). As previously stated, disadvantages for being overweight were related to not being able to play in sports or be active, other respondents said overweight could be an advantage for sports. It is important to remember that the numbers in Table 4.8 do not represent a distribution of respondents, because some respondents mentioned more than one advantage. Many mentions, as might be expected, included no advantages to being overweight. However, especially for the male respondents, weight was seen as an advantage for sports, specifically for football. This 80 advantage was stated by both males and females. INTER9 (485-488) R: (girls) can use their weight for I don't think anything. Boys, they can play football or stuff like that or wrestle. BCFIZBY (486-487; 831-832) R1: They want to gain some weight to play a sport. R2: You could throw something farther. You got more muscle you can throw farther. BCFI3B (102-106) R: He and I usually play football and you have to gain a lot of weight so that's one of the reasons why I think he gained most of his weight. Table 4.8. Responses youth gave about advantages of overweight for boys and girls irrespective of respondent's gender. Number of mentions For Boys For Girls No advantage (specifically stated) 13 12 Football/Other sports 13 1 Appearance (fat really muscle) 2 1 Too skinny-not good 5 3 Other advantages 8 8 Overweighr responses Most respondents said there were no advantages to being overweight. If an advantage was mentioned, it was related to sports and only for boys, especially those who could "replace their fat with muscle". One respondent said an advantage was getting attention from other people who want 81 to see weight loss. A quote follows from an overweight girl about advantages of overweight. OVWT3 (1267-1277) I: Do you think there are any advantages of being overweight? R: Well one. I think that there is kind of one. You don't have any false friends. Because no one wants to be friends with an overweight person. I mean no one would be friends with them just to get something. Because they don't think that they can get anything. Other considerations The next two sections report findings relevant to stigmatization, even though not enough information was received to develop understanding fully. The first section is how overweight youth expect to be treated. The question was asked to gain understanding how teasing affects youth after a long period of time. The second section is how average weight youth get treated, if they are friends with overweight youth. No question was asked specifically about this behavior, but during the interviewing process, some respondents volunteered information. oesired group artention After being teased often, a person may or may not expect to get treated in that manner all the time. Overweight respondents were asked how they want to be treated by their peers. All but one participant said they expect to be treated fairly and like everyone else. One participant said she expects to be treated "like dirt" by everyone except her friends. 82 Conse ences f ie sh' w’t an ove e' ht erson An important area for further investigation is the area of courtesy stigma (Goffman, 1963), that is whether or not an average weight youth will be stigmatized from having overweight friends. If they are stigmatized, they may not want to be friends with overweight youth no matter how friendly and nice the overweight youth is to them. Throughout the interviewing process, some youth stated that being a friend to an overweight perSon did not have any negative consequences such as getting teased themselves. Other respondents, however, stated that being a friend to an overweight person could be difficult at times. Difficulties included being teased while overweight friend was getting teased and being "looked down" on because of the friendship. INTER 7 (212-222) R: But some people like who think that they're nice and want to be their friend might be embarrassed because other kids will tease them if they're their friend. So, I mean that's a little bit how I feel even though I don't really want to pay attention to the kids who tease her. But you know I talk to her and stuff. I don't totally ignore her. INTER 10 (356-375) I: Do you think some other kids that hang around overweight kids are embarrassed by hanging around them? R: Sort of. I: Do you think so? R: Yeah. I: Why do you think so? 83 R: Especially if it's somebody the other kids don't like simple because they're overweight. It might be a little funny to be around them when they know that they don't have a very good reputation. BCFIZBY (578-585) I: Do you think that sometimes other boys might not want to hang around heavy boys...? R: Yea, because some kids are afraid too because they are hanging around with them. D. Development of a conceptnai modei As explained in the previous section (A), the process of stigmatization starts with the preconceived ideas about fat and overweight peers by nonoverweight youth (Figure 4.0). These ideas then lead to stigmatizing events (Section B). During the interviewing process, it was discovered that there are also nonstigmatizing events (Section C). The following statements will discuss the conceptualmodel (Figure 4.0) as was developed from sections A, B, and C. Nonoverweight youth processes ideas and experiences about weight they receive from family, peers, health professionals, teachers and the media. The nonoverweight youth realize peers who are fat are different from what is socially acceptable. In some situations the "differentness" of overweight peers leads to teasing them. This teasing may be enhanced by the insecurities the nonoverweight youth are feeling about themselves during early and middle adolescence. Overweight youth also receive messages about weight 84 from society and realize they do not have a socially acceptable weight. For some overweight youth, this view of self can lead to a vicious cycle. Because overweight youth get teased by others, they isolate themselves as protection from teasing, eat more for comfort, develop a low self- esteem, and, therefore are easy targets for teasing. Other overweight youth may ignore the teasing which could be viewed by others as positive, and may lead to making friends. The overweight youth not in the vicious cycle seem to be outgoing and friendly, make friends easily which leads to a friendship in which they are not stigmatized. Two areas that did not lead to stigmatization of overweight peers were friendship and popularity. Friendship of an overweight peer was most often developed in early childhood. Popularity of an overweight peer was obtained by who that person knew or if the overweight peer had an exceptional personality. The most common way nonstigmatization occurred for the overweight youth through popularity was being good in sports. This popularity was especially important for boys. The development of this conceptual model has pointed out important areas for further intervention programs. Future programs can concentrate efforts to help overweight youth break the vicious cycle in which they may be, and educate nonoverweight youth in a way that produces less stigmatizing events. 855 somummuuamm zoq .mbcmumcHOpm ow Sbwmopo cc cowbmuwmebwbm Co Hopes Htsbnoocoo 0:9 ‘0’ I‘ll" 1" cowmmTLOLQ guano: momma >Hw5mm mnmcomme mfitoz consumoaocm no mowbwusuomcH Lbso> e v unmwozuo>o / ./ mcwmmos cowumfiomH 2/ [e uaom no msmw> scoomoHOcm ,:- v bnmwozno>o mcwmmmb >Hpcwwnm monocmw _ _ t 2. >Hm>wuflmoo_ .9... _ \ f x x S. mccmwuu 0x62 =scmemeest= as see mabmbcwoomcs m“ one m>om AI combmuwwmaaflumi, gnome: Lo m3mw> accommaoom unawozno>ocoz cowbmnwbmsmwumcoz xbwamcomnoc 30:3 @000 cox on: manOdm cw coowslilllilltw_ sownmascoe . .e v dwnmccownm .o.- muscle COM wwquh—n— chasm: AHEEee momma ms @20ch mice: ccmwnu bsmwosnm>o no“: a: some 86 f o s o aire The draft of the questionnaire was developed from concepts or constructs developed during the interviewing relating to developing the theory of stigmatization of obesity in youth (Figure 4.1). The constructs included 1) teasing, 2) friendship with overweight peers, 3) appearance of self, 4) socializing with peers, 5) ideas about weight and weight loss, and 6) popularity. For example, making friends was important in nonstigmatization of overweight youth. A statement was then developed to capture that concept. The statement, "I have made at least one overweight friend this year", was designed to determine if friendship with an overweight peer was made and if that might change after an intervention program about stigmatization was presented to the individual. 87 Agree Disagree Iaasing 1. I get teased about my weight. 1 2 3 4 5 2. If I get teased, I ignore it. 1 2 3 4 5 n s wi ov ei ee s 3. I have many good friends. 1 2 3 4 5 4. I made at least 1 friend this year who is overweight. 1 2 3 4 5 O 88 5. I eat more food when I am sad or lonely. 1 2 3 4 5 6. I dislike the way I look. 1 2 3 4 5 Sooiaiiaing with peers 7. I consider myself as popular. 1 2 3 4 5 8. I consider myself a shy person. 1 2 3 4 5 9. In a new situation, I wait for others to talk to me first. 1 2 3 4 5 10.1 get involved with activities in school. 1 2 3 4 5 11.1 like to play in sports. 1 2 3 4 5 12.1 do not like to be around others because of my weight. 1 2 3 4 5 ioeas about weight and weight ioss 13.All overweight youth can lose weight if they really want to. 1 2 3 4 5 14.Weight loss is not easy. 1 2 3 4 5 15.Girls are suppose to be thin. 1 2 3 4 5 Figure 4.1. Draft of the questionnaire, including constructs, to measure stigmatization of obesity in youth. 88 E. Limitations and strengths of rhis study The qualitative nature of this study was both a strength and limitation. The advantages include: 1) validation of youth's opinions through a good rapport with interviewers; 2) time allowed for adolescents to express their opinions and concerns about a difficult topic and 3) elimination of "silly" responses by youth to surveys dealing with sensitive issues. Each of these will be discussed in more detail in the following paragraphs. This study suggested that adolescents will talk openly and honestly to an adult if the adult is open, honest and genuinely concerned about the adolescent's opinions. Although participants could have still given answers they thought the interviewer wanted to hear, the likelihood is not as great as in a survey situation because the adolescent has to talk directly to the interviewer. The interviewer put no pressure on participants to give a "right" answer. This topic of weight and overweight is a serious topic and difficult for some adolescents to discuss, especially overweight adolescents. Because the interviewing process allowed for as much time as the interviewee wanted, there was no pressure to hurry with answers and reinforcement by the interviewer was given that opinions of the adolescent were greatly valued and appreciated. Youth were also paid five dollars each for their time and their responses, important enough to record. 89 The potential for adolescents to be "amused" with this topic is great, because average weight youth "laugh at" overweight peers. Therefore, a way to diffuse "amusing" answers or not allow for "silly" responses which may be given if the adolescent could write anonymous comments was to interview and talk to adolescents, either one on one or in small groups. Limitations to this study include 1) the few number of participants and 2) the time-consuming nature of data analysis. Although many respondents answered similarly to questions asked of them, obtaining more responses from other youth around the state and the country would validate the results. The fact the qualitative data are nonrandom limits the generalizability of findings. Finding respondents, setting up interviews, obtaining data, coding and analyzing the data took a considerable amount of time. However, the good quality of data collected in this study outweighs the limitations, because explanations about a phenomenon expressed from the "heart" of the adolescents were captured in a way no quantitative survey or questionnaire could. Chapter V SUMMARY Results of this study indicate adolescents have perceptions that acceptable body size is associated with attractiveness, acceptance and ability to compete as influenced by the media and their own peer group. Overweight youth generally are not perceived as having an acceptable body size and, therefore, are not attractive, not socially accepted and are viewed as "different". Overweight youth are not only viewed as "different", but also as personally responsible for their overweight condition. Responses of adolescents suggested that overweight peers could lose weight, if they really wanted to, but choose to stay home, eat a lot and not exercise. Most overweight youth, however, responded that they were quite active and that their genetics played an important part in their weight. The perceptions of overweight youth removed the major responsibility for their condition from the individual. These findings reinforced the importance weight and appearance have for girls comparedto boys. Both male and female youth reported greater pressures placed on girls than 90 91 boys to be thin. The impact stigmatization of obesity has on a girl, therefore, is likely even more detrimental to their social development than for boys. Labelling youth as "fat" was a stigmatizing label. Certain situations, primarily gym class, were noteworthy for the potential for stigmatizing events to occur. Overweight youth viewed these times as a "no win" situation. If they participated in the required activity such as running, their peers laughed at them. If they obtained permission to be excluded from the gym activity, they were further ridiculed and embarrassed. Not all overweight youth are stigmatized, however, and the responses in this study suggest two reasons for nonstigmatization. The first reason is friendship. Respondents said overweight friends were different than other overweight peers because they were "nice", "friendly" and "fun". Being a shy adolescent and overweight was not acceptable and could lead to teasing. Unfortunately, some overweight youth hesitated in getting to know people. They seemed to hesitate, because they did not want to be hurt again by teasing remarks or be vulnerable with people they did not know. A second reason for nonstigmatization was via excellence in sports. Although overweight youth were seen by others as not capable of competing as well, some overweight, especially boys, could use their weight 92 advantageously on athletic teams such as football. Being an athlete contributed to popularity for many overweight boys. Understanding the process of stigmatization of obesity and providing ways to inform society about the psychosocial impact this phenomenon has on overweight adolescents should contribute to an understanding of how to help overweight adolescents feel more accepted. If overweight youth are less stigmatized, this should lead to improved self-concept and self-esteem. tio o t e me t By understanding the process of stigmatization, intervention programs can be initiated to help overweight youth. Sobal (1991) gives a four component model for coping with stigmatization. The steps he suggests include recognition of the problem, readiness or preparation of stigmatizing events, reaction to the events, both immediate and long term, and repair of problems that occurred during the stigmatized event. Examples of ways to help overweight youth might include improving social and relationship skills with role playing. Allen (1979) suggests that in order for overweight people to succeed in weight management efforts, they need to develop a positive body image and self-esteem by focusing on their positive characteristics and achievements. Therefore, a focus away from weight should be the first step to help 93 adolescents feel good about themselves. Educating the overweight child, however, is not enough. Efforts to educate society, especially in schools and sporting events where overweight kids are viewed negatively, also needs to be initiated. If society understands the negative impact that judging someone by his or her size has on a person, perhaps attitudes will change and less pressure placed on youth to achieve thin body shapes. Other components, such as family, can either add to the stigmatized condition or help in coping. Health professionals must relay information to their patients and the public about what is no; fully known about obesity, specifically the causes and "cures". Health professionals should help overweight people understand that their condition does not make them a "bad" person. Adolescents need to learn to view their obese peers as a whole, not just by appearance. This perspective will be difficult to teach, because many adults still have a difficult time with this. One overweight youth articulated this concept beautifully as follows. "You should really deal with the individual instead of the stereotype, because it's not just a matter of exercise and a matter of (eating less). I'm sure that helps, it helps a lot, but you have to go inside (the person) before you can go outside." APPENDIX A 94 Appendix A Recruitment of participants (Groups 1,2,3) Participants in Group 1 were recruited by the researchers through talking to people in the Lansing community. The participants were given the option to interview in the nutrition assessment lab at Michigan State University or in their home. Ten individual interviews and one focus group were included in Group 1. Participants in Group 2 were from the 4-H Exploration Days at Michigan State University and were recruited to participate in seven focus groups and one interview. The three day statewide summer workshop involves 4-H participants ages 11-18 years from every county in Michigan. Ten counties were targeted to get a variety of inner-city and rural youth. County agents were contacted to inform them of the research project and to encourage participation of their youth who were 11-15 years of age. Letters and consent forms were sent to the targeted participants and their parents. Times and places to hold focus groups for this project were arranged with the 4-H director at MSU. Participants were informed of times and places for the interviews upon their arrival to MSU. All targeted youth had the choice to participate at the times available or not. Therefore, when only one participant came to the available time, an individual interview was conducted rather than a focus group. Four focus groups and three individual interviews were conducted at the Black Child and Family Institute, a summer educational program offered to youth in the Lansing area. Contacts were made with the director and staff to set up times and places in the building to conduct the focus groups and to send parents the consent forms. Participants were told to bring signed consent forms. Because youth volunteered to participate and only one person sometimes appeared at the designated time and place, individual interviews were conducted when necessary. Participants in Group 3 were recruited by the researchers who contacted people in the Lansing and Grand Rapids area working with overweight adolescents. Because of shortage of time and problems obtaining consent from overweight youth and their parents, a small sample was interviewed. APPENDIX B 95 Appendix B MICHIGAN STATE UNIVERSITY OFFICE OF VICE PRESIDENT FOR RESEARCH EAST LANSING 0 MICHIGAN 0 48824-1046 AND DEAN OF THE GRADUATE SCHOOL March 19, 1992 Marcia Kwantes, R.D. 204 Food Science RE: OBESITY AND STIGMA IN YOUTH, IRB #92-085 Dear Ms. Kwantes: I am pleased to advise that because of the nature of the proposed research, it was eligible for expedited review: This process has been completed, the rights and welfare of the human subjects appear to be adequately protected, and your project is therefore approved. You are reminded that UCRIHS approval is valid for one calendar year. If you plan to continue this project beyond one year, please make provisions for obtaining appropriate UCRIHS approval prior to March 10, 1993. Any changes in procedures involving human subjects must be reviewed by the UCRIHS prior to initiation of the change. UCRIHS must also be notified promptly of any problems (unexpected side effects, complaints, etc.) involving human subjects during the course of the work. Thank you for bringing this project to our attention” If we can be of any future help, please do not hesitate to let us know. Sincerely, David E. Wright, , Chair University Commit on Research Involving Human Subjects (UCRIHS) DEW/pjm cc: Dr. Sharon Hoerr Dr. David Kallen OFFICE OF RESEARCH AND GRADUATE STUDIES niversity Committee on Research Involving Human Subjects (UCRIHS) Michigan State University '25 Administration Buildin. East Lansing, Michigan 48824-1046 517/355-2180 FAX; 517/336-1171 MSU is an alhrmanveaacnon, weal-opportunity Institution 96 MICHIGAN STATE 0 N l v E R s I T Y June 9, 1993 TO: Marcia Kwantes 204 Food Sciences RE: IRB #: 92-085 TITLE: OBESITY AND STIGMA IN YOUTH CATEGORY: 2-I REVISION REQUESTED: N/A APPROVAL DATE: June 6, 1993 The University Committee on Research Involving Human Subjects’ (U CRIHS) review of this project is complete. I am pleased to advise that the rights and welfare of the human subjects appear to be adequately protected and methods to obtain informed consent are appropriate. Therefore, the UCRIHS approved this project including any revision listed above. UCRIHS approval is valid for one calendar year, beginning with the approval date shown above. Investigators planning to continue a project beyond one year must seek updated certification. Request for renewed approval must be accompanied by all four of the following mandatory assurances. l. The human subjects protocol is the same as in previous studies. 2 There have been no ill effects suffered by the subjects due to their participation in the study. 3. There have been no complaints by the subjects or their representatives related to their participation in the study. 4. There has not been a change in the research environment nor new information which would indicate greater risk to human subjects than that assumed when the protocol was initially reviewed and approved. There is a maximum of four such expedited renewals possible. Investigators wishing to continue a project beyond that time need to submit it again for complete review. UCRIHS must review any changes in procedures involving human subjects, prior to initiation of the change. Investigators must notify UCRIHS promptly of any problems (unexpected side effects, complaints, etc.) involving human subjects during the course of the work. If we can be of any future elp, please do not hesitate to contact us at (517) 355-2180 or FAX (517) 336-1171. Sincerely, David E. Wright, Ph.D. UCRIHS Chair DEW:pjm cc: Dr. Sharon Hoerr Dr. David Kallen APPENDIX C 97 Appendix C CONSENT PORN Some researchers in the Department of Pediatrics/Human Development and the Department of Food Science and Human Nutrition at MSU are trying to understand why some kids your age are or are not treated well by other kids. Sometimes kids are treated differently because of how they look or how much they weigh. We would like to ask you a few questions about your opinions and feelings and about your own experience. We would also like to ask you about how others look at you. We are interested in talking with young people between the ages of 11 and 15. We will need about an hour of your time. We will talk with you privately, in your home, or someplace else convenient for you. Some of you may be asked to be part of a small group discussion at a convenient location. Some of the questions may make you feel uncomfortable, because no on has ever asked you these questions before. You may take your time answering them. If at any time you feel you do not want to answer more questions, you may tell the interviewer you want to stop. You are answering the questions as a volunteer. The care you receive in the Clinic will not change whether or not you decide to be part of this study. Your name will not be connected with the answers you give us. Your name will never be used in research articles coming from the study. The questions and answers will be recorded on a tape recorder to insure accuracy. If you decide to participate in the study and are selected to be interviewed you will receive five dollars ($5.00). This will be given to you at the end of the interview. If you do want to be part of this study we will need you to give us your name, address, and telephone number so we can contact you about a time to interview you. We will also need to have one of your parents or guardians sign the form to let us know we have their permission to interview you. 98 If you or your parents have questions about the study you can contact: Dr. David J. Kallen, Department of Pediatrics/Human Development, M.S.U. (517-353-0709) Dr. Sharon Hoerr, Department of Food Science and Human Nutrition, M.S.U. (517-349-6536) Ms. Marcia Kwantes, Department of Food Science and Human Nutrition, M.S.U. (517-882-0312) Karen Boyd, M.S.W. Department of Pediatrics/Human Development, M.S.U. (517-353-5408)7 I volunteer to take part in the study of how kids are treated. I understand that the care I receive in the Clinic will not change whether or not I decide to be part of the study. I understand that I can end the interview any time I want to. Name: Signature: Address: City State Zip Phone Date: I agree to let my son or daughter, named above, take part in this study: Parent or Guardian Signature 99 Consent Form We are trying to understand why some kids your age are treated well or not by others. We would like you to answer a few questions about your opinions, feelings, and things you have noticed about other kids your age. We would also like to ask you how you think others look at you. We will need about an hour of your time. If at any time you feel you do not want to answer any more questions, you may tell the interviewer you want to stop. You are answering these questions as a volunteer. Your name will not be connected with the answers you give us. Your name will never be used in research articles. The questions and answers will be recorded on a tape recorder. If you decide you want to participate and are chosen to be in one of the groups, you will receive five dollars. This will be given to you at the end of the questions. If any questions arise about the study, participants/parents may contact: 1)Dr. Sharon Hoerr, Dept. of Food Science and Human Nutrition, Michigan State University, East Lansing, MI.(517-355-7701) 2)Dr. David Kallen, Dept. of Pediatrics Human Development, Michigan State University, East Lansing, MI.(517-353-0709) 3)Marcia Kwantes,RD, Food Science and Human Nutrition Department, Michigan State University, East Lansing, MI. (517-355-7701) Participant's signature Parent's signature APPENDIX D 100 Appendix D Demographic and Body Image Profile Please complete the following information. This will only be used to describe the variety of. young people participating in this study. Do not writg your namg on thiggform. How old are you? What grade are you going in? Are you: A boy A girl Would you say you are (please check one): White Afro-American Other Hispanic American Indian (please specify) How much do you weigh? pounds How tall are you without shoes? feet inches How many close friends do you have (A close friend is someone you can tell your troubles to) How many are overweight? How many overweight kids your own age do you know? What does you father do on his job (Please describe in as much detail as you can--i.e. he makes cars for Oldsmobile or he sells insurance or he stays home and takes care of the house) What does your mother do on her job (Please describe in as much detail as you can--i.e. she makes cars for Oldsmobile or she sells insurance or she stays home and takes care of the house.) How much education do your parents have: - Father Mother 8th grade or less Some high school, did not graduate High school graduate Attended community college, no degree Community college grad‘ Trade or technical school graduate Attended 4 year college, not grad College graduate More than college 101 Now look at the following figures: females Which male figure looks most like your father? (please circle only one number) 1 2 3 4 5 6 Which female figure looks.most like yourlmother?(please circle only one number) 1 2 3 4 5 6 Which one looks most like you? 1 2 3 4 5 6 How many brothers do you have? How many sisters do you have? How many of your brothers look like: 1_____ 2 3 4 5 6 How many of your sisters look like: 1_____ 2 3 4 5 6 N (A .1: Ln 0 Which figure does your best friend look like? 1 Thank you for your cooperation. APPENDIX E 102 Appendix E Question Set #1 Ob ect es 0 ocus rou est'ons 1. To understand how social stigma is attached to obesity. 2. To understand how the stigma of obesity impacts weight control efforts of children and adolescents. 3. To understand how obesity impacts social and psychological development in youth(separate for boys and girls). 3a. To understand how obesity reduces self-esteem in youth 11 to 15 years of age (separate for boys and girls). cus rou nd i terview estions t add ess b' ct ves Objectives ; and z 1. What do you think it means to be overweight? to be fat? to be obese? Do you think of overweight peers and fat peers differently? If so, how? How do you know someone is the right weight? Too thin? 2. What is the first thing you notice about someone your age when you meet them for the first time? 3. What kind of kids are most likely to weigh too much? 4. How do other kids treat kids who weight too much? 5. How do teachers treat them? 6. How about kids who are too thin? 7. How do other kids treat them? 8. How do teachers treat them? 9. When you watch television, what type of people do they have on shows and on commercials-underweight, right weight or overweight? Who would you most like to be on television? Who do you think you are like now? 10. 11. 12. 13. 103 Can kids your age who are overweight lose weight if they really want to? If so, why don't they? Are any of your friends fat? If not, why not? If yes, is your friend like most fat kids or different from most fat kids? If different, in what ways? What three adjectives would you use to describe an obese girl? What three adjectives would you use to describe an obese boy? What do you think overweight kids your age do during the day? After school? On weekends? Objective 3 1. 2. 3. What do you think it means to be overweight? Is being overweight worse for boys or for girls? Why? How do you think overweight kids feel about their weight? Why or why not? Do you think overweight kids act differently in social situations than do non obese kids? Do you think overweight kids get treated differently because of their weight than do normal weight kids? If so, how? Do you think classroom teachers respond differently to obese kids than to average weight kids? If so, how? Why do you think boys/girls don't like to be overweight? Do you think some boys would like to be overweight? If so, why? What about girls? 10. 11. 104 Question Set #3 Interview questions for overweight youth What do you like to do after school? on weekends? hobby? What do you think the word overweight means? fat? obese? Would you say you have more friends, same, or fewer friends than other kids your age? Why do you think that is? How did you make friends and what do you and your friends do together? Do you have a group of kids you hang out with at school? How do you stay in that group? Tell me about your friend-close friends, what do they look like? Would you say your friend(s) is/are heavier, the same or lighter than you? What is personality like? There are some kids who get teased in school. Some kids say overweight kids get teased. Do you think that is true? What do you think they can do about the teasing? How can an overweight kid make friends? If someone new come into your school, do you think you would try and make friends with them or talk to them first or wait for them to talk to you? Why? If you wanted to be friends with this new person, how would act? How do kids treat you when they first meet you? How do you expect to be treated? Do you think some overweight kids get teased more than others? Why? Have you ever been teased by others? Please tell me about that. Some people think an overweight kid can lose weight if they really want to and others say they can't. What do you think? Do you know of any kids your age who have lost weight or tried to lose weight? How old? How did they do it? Successful? 12. 13. 14. 15. 16. 105 What do you think causes a kid your age to be overweight? Do you think there are any disadvantages to being overweight? ' Like what? Any advantages? Why is that? Is being overweight worse for girls or boys? Why? What type of people do they have on tv, underweight, avg wt or overweight? Who would you most like to be on tv? Do kids your age treat you differently because of your weight? Do teachers? In what ways do they treat you differently? Do you ever tease kids because they are overweight or too thin? APPENDIX F 106 Appendix F Categories and codes used for normal weight respondents in obesity-stigma study. Categories are in bold print. I. Overweight Defined A. B. C. D. E. Eat Weight Self misperception Appearance 1. Size 2. Flabby 3. It shows Nicer word II. Fat Defined A. B. C. D. E. F. Different (from overweight) Familial Same as overweight Flabby Really fat Size III. Obese Defined A. B. C. D. E. Size Not know what it means Not Healthy Better (nicer) word for overweight Rejected IV. Big Friend A. Descriptors 1. Neutral a. Overweight b. Fat c. Familial d. Obese 2. Positive a. Empathy for b. Shared activity c. Nicer Word 3. Negative What like 1. Same as others 2. Nice 3. Funny 107 How Met 1. Grew up with (played with) 2. Helped me 3. Friend of a friend 4. Undisclosed Have no overweight friends 1. Didn't grow up with any Big stranger A. Descriptors 1. Neutral 2. Positive 3. Negative a. Large b. Huge c. Fat,fatty d. Fig 4. Depends on mood of respondent Behaviors 1. No manners 2. Mean 3. Quiet 4. Eat too much 5. Same as normal weight 6. Get into trouble What like 1. Behaviors a. Positive (1) Shy (2) nice (3) quieter (4) sensitive (5) good personality b. Negative (1) Grouchy (2) Jealous (3 ) Mean (4) lazy (5) snotty (6) strange, different (7) dumber (8) teasers 108 VI. Overweight causes A. B. C. D. E. F. G. VII. Peer A. B. C. D. E. F. G. H. I. Eat 1. too much 2. too many sweets 3. too quickly 4. imbalanced diet 5. nothing better to do 6. irrelevant Exercise too little Familial Big for age Home problems 1. depressed Illness Gives up trying to lose weight because cannot group attention Who teases 1. boys 2. girls a. girls who hate What teasers do Behavioral consequences Blame the victim Fat kids a victims 1. no power 2. no skills New kids, not different Self exempt Fat kids not treated differently Depends on popularity VIII. Overweight Consequences/Disadvantages A. C. D. E. Emotional consequences 1. Ashamed of weight 2. feels guilty 3. don't talk about it 4. feels sad, depressed 5. low self esteem Interactional consequences 1. What does when teased a. nicer to others b. keeps cool 2. Rejected Not able to be active (inactive) Health risk Appearance 1. clothes don't fit IX. XI. 109 F. Try to lose weight Weight Loss A. Want 1. 2. to Yes No a. too much work b. too lazy c. hard to do d. give up because teased when unsuccessful B. Can they 1. Yes 2. No a. familial C. How to 1. Exercise 2. Change eating habits a. Eat better b. Eat less c. Don't ask for food d. Eat less often 3. Grow D. Some should not Gender Comparisons A. Girls 1. 2. B. Boys 1. 2. 3. Worse for girls a. Social Consequences b. Appearances (1) early developers Don't tease Built Strong big C. Same for boys and girls Advantages of Overweight A. Boys 1. 2. 3. 4. 5. Dating Athletics a. swim better (because float) Strength Appearance a. look built None 110 Girls 1. Food capacity a. Hold more food 2. Appearance 3. None XII. Popularity of overweight kid A. B. How to 1. Resources -a. money b. nice c. act 'bad' d. good talker e. good fighter f. good dresser g. good sense of humor Personal characteristics a. Courage and strength b. Good grades 1. Reputation a. fat person have own group of friends Exemptions to stereotype 1. Some run fast 2. Play basketball 3. Good at sports Treatment of stigma Presentation of self 1. Appearance a. smiles 2. Behaviors a. nice b. approachable Ignores teasing XIV. Underweight defined XV. A. Appearance 1. size First impression of others A. Physical appearance 1. size a. height b. waist 2. face 111 Presentation of self 1. personality a. nice b. what like 2. talk to me first XVI. Teachers A. B. XVII. XVIII. A. B. No different Treat better 1. talk to more Media T.V. 1. All body types 2. Thin preferred 3. Overweight treated differently 4. Average size=pretty Models 1. Kurt Russell 2. Charles Barkley 3. 90210 4. Saved by the Bell 5. None (so stated Consequences to normal weight friendship with overweight peer Teased Scapegoated APPENDIX C 112 Appendix G An example of a coded interview from the Ethnograph printout. CODED VERSION OF INTER4HW 11/17/1993 23:15 Page 1 #-IIF #-II MK: How would you define the word fat? 1 -# I a W: Big 4 -# #-IIF #-II I MK: What things do you look at to know 6 : someone is big? Or do you look at anything? 7 i Or do you compare people? What does big 8 . mean? 9 l W: What does it mean? Not small. 11 § MK: How do you know if someone is big? 13 g l W: Because you look at them. 16 ; I MK: And you can just tell by looking 18 g at them? 19 : W: Yea 21 —# #-IIG #-II MK: What is the point that someone is 23 . big and not big, how do you determine if 24 ' that person is big or just smaller than 25 : big person but not considered big, do you 26 . see what I mean? How do you know? 27 : W: How do I know if they are big or not? 30 i Like if they weigh over 180 pounds. 31 -# #-IIIB #-III MK: What does the word obese mean? 34 -# Have you heard of that word? 35 3 W: NO 37 -# #-IIC #-II MK: Okay, what about the word overweight. 39 -# What does that meant to you? 40 3 W: Fat, just fat. 43 -# 113 CODED VERSION OF INTER4HW 11/17/1993 23:15 Page 3 MK: Anything else? What does she like to 99 : do? 100 . W: She likes to jump rope and she likes 102 1 to walk and she likes to go to parks and 103 i stuff. 104 -# #-IVB #-IV #-XIIIA #-XIII #-VB #-V MK: Is she different than most heavy 106 -# kids? 107 i W: Yea 109 : MK: How is she different than them? 111 i W: Because she don't like try and hide 113 ; it. 114 . I MK: How do other kids try and hide it. 116 I I W: Wearing big clothes. 119 -# MK: So she doesn't try and wear big 121 clothes and try and hide it. Is she 122 different in any other ways from other 123 heavy kids? 124 W: NO 126 #-VB #-VIA #-VIB #-V #-VI MK: What do you think heavy kids do on 128 -# weekends or after school? 129 i W: Go home, sit in front of the TV and 131 3 eat. 132 —# MK: What are their personalities like? 134 #—VA #-VC #-V W: I don’t know. They probably believe 138 -# in a lot of stuff on television. 139 f MK: They believe in a lot of stuff on 142 ; television? 143 . I W: And always talk about food. 145 -# MK: What types of things do you think 147 they believe in on television? 148 114 CODED VERSION OF INTER4HW 11/17/1993 23:15 W: Soap operas. #-VB5 #-VB #-V MK: Okay. Are any of these kids mean? W: Some of them. MK: Some of them, but not any more so than average weight kids? W: Yea #-IXBl #-IXA1 #-IXB #-IXA #—IX MK: Okay, do you think these heavy kids can lose weight if they really want to? W: Yea. MK: Why don't you think they do? #—IXA2 #-IXA #-IX W: Cause they don't have anybody to tell them that they need to lose weight. #-IXC1 #-IXC #-IX MK: What types of things do you think they can do to lose weight? W: Can go walking to work and ride their bike. MK: Anything else? W: Walk around the block. #-IXC1 #-IXC #-IX MK: Do you think your friend can lose weight if she really wants to? W: She is. MK: How is she doing that? W: How is she doing it? She plays double dutch and she walks always walks up to Franklin Park. MK: Is she aware of that or she just does it because she likes to not because she wants to lose weight? Page 4 150 152 155 157 158 160 162 163 166 168 170 171 174 175 177 178 180 182 184 185 187 189 191 192 193 195 196 197 I --<¢ I #..- --.-- .. 115 CODED VERSION OF INTER4HW 11/17/1993 23:15 Page 5 W: Yea 200 #-VIIB #-VII MK:Okay, Some people make fun of kids 202 -# who are heavy, have you ever heard of 203 I teasing? Why do you think they do that? 204 I I W: I don’t know. Because they think 207 3 it’s funny. 208 3 I $-VA3 $-VA $-V I MK: What part makes it funny to them? 210 f$ I W: Like if they got a pot belly. 213 is I MK: Do you think ever that kids who 215 I tease the heavy kids, they want to try 216 : and make themselves look good by teasing 217 1 others, does that, do you think that 218 I might be true? 219 : I W: Yea. 221 —# #-VIIA1 #-VIIA #-VII MK: Because a few other kids had 223 ' mentioned that too, I was wondering if 224 . you would agree with that? A couple 225 . other kids have mentioned to me that 226 ‘ they thought that guys who were in sports 227 I groups seem to tease the heavier girls 228 . more. Do you think that is true or not? 229 , I W: Yea 232 t l MK: So you think they tease more than 234 ' than the guys who are not in sports? Why 235 ' do you think they do that more? 236 : I W: Because they like the in shape girls 238 I like the cheerleaders and stuff. 239 -# #-XVIII MK: What do the friends of heavy girls do 242 -# when they hear other boys making fun of 243 . their heavy friend? Do they do anything? 244 I Do they tell them to stop? Do they not 245 , say anything or do they try and defend 246 their heavy friend? 247 = W: Sometimes they don’t say 250 I 116 CODED VERSION OF INTER4HW 11/17/1993 23:15 anything. Sometimes they tell them to stop teasing them. MK: Do they stop then? W: Sometimes. #-VIIIB #-VIII $-XIII #-XC MK: Are there any heavy kids that say things back? W: Yea MK: They do? What do they say back to them? W: I don't know. ‘They might say "you gonna be fat when you grow up too." MK: Those kids that do that, do you think that they feel better about themselves or do you think that, um, when they can give remarks back like that, are they any different than other heavy kids that just don't say anything? Do you see what I mean? The heavy kids that maybe don't say anything, do they get teased more? W: Yea #-X ‘ MK: Do you think being overweight is worse for boys or girls or the same? W: Um... the same. MK: Why do you think it is the same? W: Because they are not that much different. 1#-XIA2 #-XIA #-XI #4VC4 MK: Do you think there are any times that boys would like to be overweight? W: Maybe, if they were like football player. #-IVC #-IV MK: How many heavy friends do you have? Page 6 251 252 254 256 258 259 261 263 264 266 267 270 271 272 273 274 275 276 277 280 282 283 286 288 291 292 294 295 298 299 301 I #5.... __.. ..._ -- I =u:— -- -— -- -—:n: 117 CODED VERSION OF INTER4HW 11/17/1993 23:15 Page 7 W: About five. 304 -# MK: We talked about if they were different 306 or if they are the same. You said they 307 are different because they don’t try and 308 hide it. Is that true for all five of 309 them that are heavy? 310 Rest of answers taken from notes. 313 W: Some try and hide it, same as other 315 overweight kids. 316 MK: What types of groups do you have in 318 your school? 319 W: Nerds, preppy, jocks. Can’t name 321 any others. 322 MK: Which ones have heavy kids? 324 W: Nerds, preppies, not jocks. 325 #-XII $-XIIA2 $-XIIA MK: How would a fat kid get popular? 327 —# I I W: Hang around with other popular people. 330 -# #-VIIIE #-VIII MK: What are disadvantages of being 333 -# overweight? 334 I I W: When go shopping, only have small 336 : sizes. Food is more expensive because 337 I they eat more. 338 -# #-XIA4 #-XIBZ #-XIA #-XIB #-XI MK: What are some advantages? 340 -# I W: Don't worry about being underweight. 342 : It's better to be overweight but not too 343 , much. Too much would be 200-300 pounds. 344 , The same for boys and girls. 345 —# APPENDIX H 118 Appendix H An example of an Ethnograph printout by code. SORTED OUTPUT FOR FILE OVWTl 11/17/1993 23:19 Page 1 SORT CODE: I OVWTl Brandy SC: I #-I Brandy: Ok, um, lets see people who are 41 -# around my age, say when your thirteen and 42 # your supposed to weigh 100 lbs and you 43 # weigh 190 or something. 44 -# SORTED OUTPUT FOR FILE OVWT2 11/17/1993 23:19 Page 1 SORT CODE: I OVWT2 do you thi SC: I #—IA #-I : do you think, what’s your opinion on what 58 -# the word overweight means? 59 # # 2:People who are there's average weight 61 # that you’re supposed to be but people 62 # who are over that average, but I think 63 # their just the same as other people and 64 # I don’t think people should treat them 65 # different. 66 -# OVWT2 fat. What SC: I #-IB #-I : fat. What one would you use do you know? 93 —# # 2:Probably overweight. 96 # # km:Okay. Because fat is more of a tissue 98 # you said. More of a substance. 99 # # 2:Um Humm. 102 -# 119 SORTED OUTPUT FOR FILE OVWT3 11/17/1993 23:19 Page 1 OVWT3 SH SC: I #-I SH: Well what do you think the word 262 -# overweight means? 263 # # . Jenny: Well, technically it means that 265 # - you weigh more than what the usual is for 266 # your age and height. But like the other 267 # kids see it like if you have a little bit 268 # of a stomach or something like that. 269-# SORTED OUTPUT FOR FILE OVWT4 11/17/1993 23:19 Page 1 OVWT4 MK SC: I #-I MK: What do you think the word overweight 1W5-# means? 177 # 1: I don't know. 179 -# OVWT4 would come SC: I #—I #-II #-III would come to your mind? Or why would you 1%9-# say that? In other words when would you 200 # think a person is over weight or when would 201 # you think a person is fat? 0 when would you 202 # think a persons obese. 203 # 1: I don’t know the opinion is theres I 206 # don't go around judging other people. 207-# 120 SORTED OUTPUT FOR FILE OVWT7 11/17/1993 23:19 Page 1 SORT CODE: I OVWT7 MK SC: I #-I MK: What do you think in your own words do 55 -# you think the word overweight means? 56 # # 1: Um, lets see. I think, cause I don’t 59 # . really believe in the charts where it says 60 # - you should be in between this weight 61 # because I think its different for every 62 # person but, I think that overweight means 63 # that it begins to effect your health or 64 # that it could effect your health. 65 -# SORTED OUTPUT FOR FILE OVWT8 11/17/1993 23:19 Page 1 SORT CODE: I OVWT8 MK SC: I #-I MK: Right definitely. All right what do 33 -# you think the word overweight means? 34 # # 1: Weight more than you should probably. 37 # SORTED OUTPUT FOR FILE OVWT9 11/17/1993 23:19 Rqfial SORT CODE: I OVWT9 MK SC: I #-I MK: Why do you think you need to? 448 -# # 1: Because I'm not average weight. I’m 450 # overweight. 451 # # MK: How do you determine that? _453 # # 1: I guess, I’m bigger than the average 455 # person my age. 456 -# 121 SORTED OUTPUT FOR FILE OVWT9 11/17/1993 23:19 Page 1 SORT CODE: I OVWT9 words. Wh SC: I $-I . words. What do you think the word overweight 37 -$ ~ means? 38 $ $ 1: Over the weight of average people. 40 $ Bigger than other people. 41 $ $ MK: 0k, what do you think determines what 43 $ average weight is? Who determines what 44 $ determines it? 45 $ $ 1: Well I guess it kind of depends on what 47 $ you height is. You should be proportional 48 $ to your height. 49 -$ SORTED OUTPUT FOR FILE OVWTlO 11/17/1993 23:19 Page 1 SORT CODE: I OVWTlO MK SC: I #-I MK: 0k. What do you think the word 50 -# overweight means? 51 # # 1: Well, overweight is like it different 53 # through everybodys eyes because not everybody 54 # thinks the same so I would have to say its like 55 # somebody that would just be a little bit heavier56 # than what the considered average weight for 57 # your height and age would be. 58 -# APPENDIX I C. 122 Appendix I Categories and codes used for overweight respondents in obesity-stigma study. Categories are in bold print. I. Overweight defined A. Weight 8. Nicer word-describing a friend II. Fat defined A. Same as overweight III.Obese defined A. Not known B. Technical term IV. Friendship A. Friends ~ 1. Have own group a. Yes b. No 2. Appearance 3. What like 4. How meet 5. Response of friend to others teasing B. Making friends 1. Cautiously 2. Outgoing 3. Don't 4. Safe 5. Nice C. Qualities for friendship 1. Reasons V. Approaching strangers VI. Overweight causes 1+. 123 VII.Feer group behavior A. Desired group attention B. Teasing 1. 2. 3. 4. 5. 6. 7. 8. Where a. Middle school b. High school c. No Who teases What teasers do Who gets teased Why teasers tease overweight kids What being teased is like Overweight kid's response to teasing a. b. c. d. e. f. Reject the teaser Confront Ignore High self-esteem Low self—esteem/eat/feel bad Blame teasers Overweight kid as teaser C. Acceptance from others VIII.Overweight consequences/disadvantages IX. A. None B. Appearance C. Others Weight loss A. Can lose weight if want to 1. 2. Yes NO B. How to lose weight Eat less/better Exercise Know someone 1. 2. 3. C. Weight management technique of self D. Weight management technique of others E. Social support F. Barriers to weight management 124 X. Gender comparisons A. Worse for girls 1. Social/no boyfriends B. Worse for boys C. Same XI. School A. Size 1. Rejection B. Change from middle school XII. Popularity of overweight kids A. Number of friends B. Good in sports C. Who you know XIII.Activities A. 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