i How Does Stigma Influence One`s Perception of Obesity?

 i How Does Stigma Influence One’s Perception of Obesity? The Relationship Between Obesity,
Locus of Control, and Depression
Paulina Coutifaris
Submitted in partial fulfillment
of the requirements for a B.A. in Psychology
at Franklin & Marshall College
May 2015
ii ACKNOWLEDGEMENTS
I would like to acknowledge the Department of Psychology at Franklin & Marshall
College for its approval of this study. I would also like to thank the Committee on Grants for
funding this study. I would like to thank my primary advisor, Professor Christina Abbott, and my
secondary advisor, Professor Allison Troy, for their dedication to this project. Their constant
encouragement and guidance were present throughout the research process, and their advice in
designing the study and assistance in analyzing the data was extremely helpful. I would also like
to thank my committee members, Dr. Michael Penn and Professor Megan Knowles, for taking
the time to read and critique the study for my defense.
iii TABLE OF CONTENTS
Page
INTRODUCTION……………………………………………………………………
1
Stigma……………………………………………………………………......
2
Obesity and Depression………………………………………………………
3
Locus of Control……………………………………………………………...
4
Internalization of Stigma……………………………………………………..
6
Hypothesis……………………………………………………………………
7
METHODS…………………………………………………………………………..
8
Participants…………………………………………………………………..
8
Research Design………………………………………………………….....
8
Materials…………………………………………………………………….
9
Demographics……………………………………………………….
9
Locus of Control…………………………………………………….
9
Self-Esteem…………………………………………………………
10
Depression…………………………………………………………..
10
Weight Specific Locus of Control…………………………………..
11
Stigma………………………………………………………………
11
Procedure……………………………………………………………………
12
RESULTS……………………………………………………………………………
14
Descriptive Statistics…………………............................................................
14
Multiple Linear Regressions…………………………………………………
14
Predicting Depression………………………………………………..
14
Predicting Self-Esteem………………………………………………
15
iv Binary Logistic Regression…………………………………………………
16
DISCUSSION………………………………………………………………………
18
Limitations and Implications……………………………………………….
20
Future Research…………………………………………………………….
21
REFERENCES……………………………………………………………………..
23
APPENDIX A. STATEMENT OF INFORMED CONSENT……………………..
30
APPENDIX B. DEMOGRAPHICS………………………………………………..
31
APPENDIX C. ROTTER’S LOCUS OF CONTROL SCALE……………………
32
APPENDIX D. ROSENBERG SELF-ESTEEM SCALE…………………………
35
APPENDIX E. BECK DEPRESSION INVENTORY…………………………….
36
APPENDIX F. INTERNAL VERSUS EXTERNAL WEIGHT LOCUS OF
CONTROL SCALE………………………………………………………………..
38
APPENDIX G. STIGMA QUESTIONNAIRE……………………………………
39
APPENDIX H. DEBRIEFING FORM…………………………………………….
40
iv LIST OF TABLES
Table
1
Page
Central Tendency and Variance for BMI, LOC, Depression,
and Self-Esteem………………………………………………...
14
2
Change in Depression Predicted by BMI and LOC…………….
15
3
Change in Self-Esteem Predicted by BMI and LOC……………
16
4
Binary Logistic Regression Predicting Likelihood of Stigma….
17
v LIST OF FIGURES
Figure
Page
1
Moderating Model Illustrating Hypothesis……………………
8
2
Procedure……………………………………………………..
13
3
Depression Increases as a Result of BMI and LOC………….
15
4
Self-Esteem Decreases as a Result of BMI and LOC…………
16
vi ABSTRACT
Obesity is a serious and prevalent condition in the United States, with high risk for physical and
mental morbidity and mortality. Previous research suggests that obesity and depression are
causally linked with a focus on the responsible biological, psychological, and social mechanisms.
This study aims to identify personality characteristics, specifically, locus of control, that may
moderate the relationship between obesity and depression. A sample of 250 adults from the
United States was recruited using Amazon Mechanical Turk. An online questionnaire was
utilized to assess demographics, body mass index (BMI), locus of control, depression, and selfesteem. Overweight and obese participants with a BMI over 25 and an external locus of control
had marginally significant higher depression scores and significantly lower self-esteem scores
compared to normal weight participants with an internal locus of control. Secondary analyses
found that participants who were younger, had a high BMI, and experienced greater depression
were significantly more likely to experience societal stigma. This research is one of the first to
evaluate whether locus of control moderates the relationship between obesity and depression.
Personality specific intervention programs should be created to reduce obesity and depression
among a group of external individuals who lack self-motivation, and depend on outside factors to
promote self-change.
1 INTRODUCTION
Obesity is a serious public health epidemic in the United States. More than one-third of
adults (34.9%) and 17% of children are obese (Ogden et al., 2014). This widespread emergence
of obesity across the United States has been labeled as an “obesity crisis” by the media and
medical community (Brownell & Horgen, 2013). Obesity has recently been classified as a
diagnosable condition in the Diagnostic and Statistical Manual of Mental Disorders (Marcus &
Wildes, 2012) and is associated with negative health outcomes such as heart disease and diabetes
(Must et al., 1999; Pi-Sunyer, 1993), functional impairment (Fontaine & Barofsky, 2001), and
increased mortality (Allison et al., 1999). Furthermore, obese individuals can suffer from longterm mental health problems, such as depression (Marcus & Wildes, 2012).
Obesity is identified as an excess in body fat caused by a long-term imbalance between
energy intake and energy expenditure, resulting in the storage of non-essential adipose cells, also
known as fat tissue (Marcus & Wildes, 2012). While there is no clear demarcation between
normal and abnormal levels of body fat, obesity is commonly determined by one’s body mass
index (BMI). BMI is a measure of body fat based on a ratio of weight to height that is calculated
by weight divided by height. BMI is most commonly used to operationally define obesity
(Marcus & Wildes, 2012). Category thresholds have been established by BMI; a BMI greater
than 25 is identified as overweight and 30 or greater is considered obese (Marcus & Wildes,
2012).
The increased prevalence of obesity may be attributed to an increase in caloric intake and
a decrease in physical activity. Our culture and environment has created an obesogenic
environment influenced by surroundings, opportunities and lifestyle conditions (Lake &
Townshen, 2006). For example, the availability of super size portions and the lack of bike lanes,
2 safe parks, and nature trails, lead to a more sedentary lifestyle. Furthermore, many adults in the
United States spend a large portion of the workday behind a desk. These factors contribute to the
obesogenicity of an environment. However, at an individual level, the causes of obesity are
heterogeneous and involve a complex interplay among genetic, psychological, environmental,
and social factors (Bray & Champagne, 2005).
Stigma
Stigma is understood as a social construct influenced by cultural, historical, and
situational factors (Dovidio, Major, & Crocker, 2000). An individual or group that is stigmatized
is perceived to be different from normative expectations due to undesirable characteristics, which
lead to a devalued identity within social contexts (Dovidio, Major, & Crocker, 2000). Observable
conditions, which are easily identifiable, such as weight, make a person more vulnerable to
social rejection and may be used by society to define one’s identity negatively. Characteristics
that are perceived to be controllable and are viewed to be the responsibility of the person bearing
the stigma, such as appearance or weight, are more likely to be degraded and alienated (Crandall,
2000). Obese individuals are vulnerable to stigma and face social exclusion and discrimination in
a variety of facets of their lives (Carr & Friedman, 2005). Stigma perpetuates social and
psychological consequences such as avoidance, rejection, and marginalization within society.
Stigma and discrimination towards obese persons are pervasive and pose numerous
consequences for their psychological and physical health. Obese individuals are often labeled as
lazy, weak, unsuccessful, unintelligent, and undisciplined (Brownell et al., 2005; Puhl &
Brownell, 2001; Puhl & Huerer, 2009). These stereotypes carve a pathway for stigma, prejudice,
and discrimination in the workplace, health care facilities, educational institutions, and the media
that can extend to their interpersonal relationships with friends and family (Brownell et al., 2005;
3 Puhl & Brownell, 2001; Puhl & Huerer, 2009). Negative attitudes and stereotypes directed at
obese persons have been reported by employers, colleagues, teachers, physicians, nurses,
medical students, peers, friends, and relatives (Brownell et al., 2005; Puhl & Brownell, 2001;
Puhl & Huerer, 2009; Puhl & Latner, 2007). Furthermore, recent estimates suggest that weight
discrimination has increased by 66% over the past decade (Andreyeva et al., 2008) and is
comparable to the prevalence rates of racial discrimination in the United States (Puhl et al.,
2008). Unfortunately, weight stigma as a social problem in this country has not been challenged.
Prevailing societal stigma has placed blame on obese individuals for their condition; there is a
misperception that weight stigmatization is justifiable because obese individuals are personally
responsible and the stigma may be a useful tool to motivate obese persons to adopt healthier
behaviors. However, previous research conducted by Puhl and colleagues (2010) suggests that
weight stigma is not a beneficial public health tool for weight loss but instead stigmatization
poses serious risks to obese persons and perpetuates negative psychological and physical wellbeing.
Obesity and Depression
While the effects of obesity on physical health have been studied extensively, the
consequences of obesity on mental health are less certain. There are conflicting studies linking
obesity and depression. Individuals who suffer from obesity are at risk of developing depressive
symptoms and the opposite is true as well, those who are depressed are at risk for becoming
obese. Lupino and colleagues (2010) performed a longitudinal study to assess whether obesity
increases the risk of developing depression and conversely, whether depression increases one’s
risk of becoming obese. They found a bidirectional association between obesity and depression;
obese persons had a 55% increased risk of developing depression over time whereas depressed
4 individuals had a 58% increased risk of becoming obese (Lupino et al., 2010). In addition,
Roberts and colleagues (2004) examined a community sample of middle-aged and older adults
and found that 7.4% of normal weight participants were depressed, compared to 15.5% of obese
participants. More importantly, among those not already depressed, obesity at baseline predicted
depression one year later (Roberts et al., 2004). Despite directionality, both associations serve as
a pervasive risk for comorbid obesity and depression.
However, not all obese persons experience depressive symptoms. While there are
biological, social, and psychological factors that contribute to the onset of depression in obese
individuals, personality traits have yet to be fully examined. It is possible that personality traits
such as locus of control may protect some obese individuals from developing depression.
Locus of Control
Personality traits can be defined as stable, fundamental dimensions of our personality that
can influence our thoughts and behaviors in a variety of situations (Ryden et al., 2003). One
widely studied personality trait, locus of control, refers to the extent to which an individual
believes he or she can control events affecting him or her. According to Zimbardo (1985)
internal locus of control orientation is our interpretation of whether the outcome of our actions
are the result of what we do; whereas external locus of control is the result of factors in the
environment. Therefore, individuals with an internal locus of control believe that outcomes are
contingent upon personal action. In contrast, those with an external locus of control tend to
believe that an outcome is determined by outside circumstances or chance and therefore, they
cannot control the subsequent consequences.
Previous research suggests that contrasting social responses exist among individuals with
an internal versus an external locus of control. Brockner (1979) suggests that people with high
5 external locus of control (referred to as “externals”) are more responsive to self-relevant social
cues. Furthermore, these individuals conform more to society’s norms and expectations (Biondo
& MacDonald, 1971; Davis & Davis, 1972; Doctor, 1971; Pines & Juilian, 1972). However,
those with an internal locus of control (referred to as “internals”) tend to resist external
influences and tend to withdraw from social interactions (Biondo & Macdonald, 1971).
Furthermore, internals demonstrate psychological reactance (Brehm, 1966). Psychological
reactance occurs in response to threats when one believes their behavioral freedom is being
threatened (Brehm, 1966). When someone is heavily pressured to accept a certain view or
attitude, reactance can cause one to adopt or strengthen an attitude that is contrary to their initial
view. In the context of obesity and stigma, reactance can be powerful tool that enables one to
reject negative stereotypes. These contrasting social responses of externals and internals may
promote the onset of poor psychological health due to one’s openness or resistance to social
influence.
There is extensive research highlighting the differences between externals and internals
in the context of health related behavior. There is consistent evidence that internals manifest
more positive health-related activity than externals. Strickland (1978) emphasizes that internals
are more sensitive to health messages and have an increased knowledge about health conditions;
therefore, they attempt to improve physical functioning and are less susceptible to physical and
psychological dysfunction. In support of Strickland, previous research suggests that internals
seek out more health related information, assume greater responsibility for their health, and take
greater precautions to protect their health (Wallston, Maides, & Wallston, 1976). Furthermore,
Hjelle and Clouser (1970) found that internals were more likely to change their attitudes when
presented with compelling messages. This research suggests that internals are more likely to alter
6 their behavior in a positive direction when faced with health decisions. For example, James and
colleagues (1965) found that non-smokers were more likely to be internals than externals. In
addition, Platt (1969) found that internals were more likely to change smoking behaviors to a
greater extent than externals that believed that outside forces would change their behavior for
them. These findings have been reproduced in other studies; for example, internal females are
more likely to practice safe sex compared to their external counterparts (Lundy, 1972;
MacDonald, 1970). Internals generally demonstrate more positive behaviors and social responses
that may be beneficial in the face of stigma.
There has been strong evidence illustrating the positive relationship between external
locus of control and depression (Aiken & Baucom, 1982; Johnson & Sarason, 1977). Previous
research has highlighted externals susceptibility to depression due to a lack of goal directed
behavior and feelings of purposefulness (Abramowitz, 1969). In addition, externals have
increased social awareness and responses and thus, may be more vulnerable to internalizing
negative social stigma.
Internalization of Stigma
Internalization is a construct that describes a continuum in which a social value is
adopted as one’s own and the individual identifies with it (Ryan & Connell, 1989). It is the
process of consolidating and embedding society’s attitudes, beliefs, and values into oneself.
However, internalizing experiences of stigma may motivate unhealthy behaviors and negative
emotional well-being (Puhl et al., 2007). Internalization may influence one’s evaluation of self
by drawing their focus inward to their personal inadequacies—being overweight, lazy, or
incompetent. Therefore, this increased internal focus may lead one to evaluate his or her
behavior in a negative manner and to blame oneself for his or her personal behavior. In turn, one
7 may perceive oneself to possess little ability and capacity to change his or her appearance and
behavior. Those with internalizing attitudes tend to report higher levels of depression due to
experienced failure in a social domain such as being rejected, ignored, and stigmatized by peers
(Han, Weiss, & Weisz, 2001).
In the context of anorexia and bulimia nervosa, individuals experience societal pressure
to be thin and internalize the thin body ideal highlighted in the media (Stice et al., 1994). Thinideal internalization refers to the extent to which an individual embraces socially defined labels
of attractiveness and engages in behaviors designed to achieve these ideas (Thompson & Stice,
2001). Those who have internalized the thin ideal develop cognitive schemes that associate
thinness with beauty, happiness, and popularity (Tiggemann, 2002). The process of
internalization can be damaging both physically and mentally for individuals with eating
disorders as well as obese persons. Although the idea or belief that is internalized differs among
individuals with anorexia and bulimia compared to obese individuals, both groups engage in
internalization that can be harmful to physical and mental health.
While the relationship between obesity and depression has been studied and research
suggests that obesity perpetuates the onset of depressive symptomology, there is little research
on the impact of locus of control on the mental health of obese individuals. Previous research
suggests that internals resist social influence or pressure and engage in healthy behaviors. This
contrasts sharply with externals that tend to participate in unhealthy social behaviors. Therefore,
I predict that overweight and obese persons who report having an external locus of control will
be more vulnerable and internalize society’s negative stigma towards obesity and thus, interpret
obesity as a negative entity attributed to his or her identity. This process may provoke the onset
8 of depression. Consequently, I hypothesize that there will be an interaction of obesity and locus
of control that is predictive of depressive symptomology. See Figure 1.
Figure 1. The interaction between body mass index and an external
locus of control will predict depression.
METHODS
Participants
The study consisted of 253 United States citizens recruited via Amazon Mechanical Turk.
3 participants were excluded from the sample due to extremely high BMI scores above 50. The
sample included 142 males and 107 females. Participants were between 18 and 74 years of age
with a mean age of 36.12. 195 (78%) participants were white, 19 (7.6%) were African American,
12 (4.8%) were Hispanic, 17 (6.8%) were Asian, and 6 (2.4%) were categorized as other.
Participants were compensated 50 cents at the conclusion of their participation in the study.
Research Design
The current study used a within and between subjects design to examine the interaction
between obesity, locus of control, and depression. Participants were asked to complete a series of
9 questionnaires concerning demographic information, locus of control, depression, and stigma. In
addition, participants completed a self-esteem questionnaire that was used for exploratory
analyses in relation to the other variables. Body Mass Index (BMI) was calculated by asking
participants for his or her most recent measured weight and height. BMI was compared to the
variables measured in the surveys. The independent variable was classified as BMI and locus of
control orientation. The dependent variables consist of self-esteem, depression, and the
experience of stigma.
Materials
Informed consent was obtained from each participant prior to the start of the study
(Appendix A). The consent clearly stated what was required of the participant, the length of the
study, and the importance of their role in the study.
Demographics. Demographics were obtained from each participant (Appendix B). This
questionnaire consisted of five questions regarding gender, age, ethnicity, and most recently
measured weight and height.
Locus of Control. Rotter’s Locus of Control Scale is a 29-item questionnaire used to
measure internal and external locus of control (Tiggeman & Lange, 1981) (Appendix C). This
scale is a forced choice paradigm in which a person chooses between an internal or external
interpretation. Rotter’s scale is a multidimensional design used to predict a person’s internal or
external interpretation across a variety of domains. The scale is scored on a continuum; a high
score represents an external locus of control whereas a low score indicates an internal locus of
control. Each question is assigned 1 point based on its corresponding answer. An example from
Rotter’s scale is (a) many of the unhappy things in people’s lives are partly due to bad luck or (b)
people’s misfortunes result from the mistakes they make. Six items are included as distractor
10 items and these are 1, 8, 14, 19, 24, and 27. Rotter’s scale has a test-retest reliability of .61
(Tiggemann & Lange, 1981) and has been used extensively in different circumstances to
measure locus of control.
Self-Esteem. The Rosenberg Self-Esteem Scale (RSE) was used to measure self-esteem
(Rosenberg, 1965) (Appendix D). This is a 10-item self-report instrument that was developed to
assess the degree of an individual’s overall self-esteem. The measure contains items related to
individual self-esteem that the participant responds to based on their agreement to the statements
using a Likert response scale 1 (strongly agree) to 4 (strongly disagree). For example, statements
include, “I feel that I have a number of good qualities”, “I am able to do things as well as most
other people”, “I feel I do not have much to be proud of”, or “at times I think I am no good at
all” (Rosenberg, 1965). The scale ranges from 0-40 and scores between 15 and 25 are within
normal range for self-esteem whereas scores below 15 suggest low self-esteem. Scores are
calculated by reversing the scores for items 3, 5, 8, 9, and 10 and then taking the sum of the
scores (Schuster et al., 2013). The RSE scale measures an individual’s global self-esteem and has
been subject to evaluations. The RSE is frequently used in research and has high reliability and
test-retest correlations ranging from .82 to .88 (Kalpidou et al., 2011). This test also has high
internal consistency as well as strong convergent validity (Kalpidou et al., 2011; Rosenberg,
1965; Schuster et al., 2013).
Depression. The Beck Depression inventory (BDI) is a 21-item self-report instrument
that was developed to assess the degree to which a person suffers from symptoms of depression
(Beck, 1961) (Appendix E). The measure contains items related to the cognitive and affective
symptoms (e.g., sadness, guilt, pessimism), as well as somatic symptoms (e.g., loss of appetite,
insomnia) associated with depression (Eack et al., 2008). Items are rated on a scale of 0 (not at
11 all) to 3 (severely) for how much each item has bothered the participant’s functioning during the
last month. Question 9 was removed due to content containing suicide ideation. Question 18 was
removed due to content containing appetite loss and gain. Total scores on the BDI range from 063, with scores between 11-16 indicating mild depressive symptomology, and a score above 20
indicating the presence of moderate to severe depressive symptoms (Beck, 1961). The BDI has
been subject to psychometric evaluations among a variety of populations, which have indicated
that the instrument is highly consistent, reliable, and converges with other measures of
depressive symptomology.
Weight Specific Locus of Control. The Internal versus External Control of Weight Scale
(IECW) measures locus of control pertaining to weight loss (Tobias & MacDonald, 1977)
(Appendix F). The 5-item measure was used to assess achievement of a goal, that being weight
loss, as contingent or noncontingent on one’s behavior. Items are arranged in a forced choice
format and one choice reflects an internal orientation and the other reflects an external
orientation. Scores range from 0-5. The first alternative in item 1, 3, and 5 and the second
alternative in 2 and 4 reveal external choices. All external choices are scored 1 and all internal
choices are scored 0. Total scores are the sum of the external options selected by the participant.
Reliability was determined using test-retest correlations and was about .52.
Stigma. The way in which participants interpret stigma towards obesity or body image
was measured using a 3-item questionnaire (Appendix G). The first question was, “do you
experience stigma based on weight or body image?” The participants responded to this question
by either answering yes or no. The participants responded to the following two questions based
on their agreement to the statement on a Likert response scale from 1 (strongly disagree) to 4
12 (strongly agree). Statements include, “do you feel the stigma reflects negatively on yourself”,
and “do you feel the stigma reflects negatively on society.”
Procedure
Participants completed the study using Qualtrics, an online survey system that they have
access to via Amazon Mechanical Turk. After clicking on the link, they were shown an informed
consent form. They were asked to read this form and verify that they did so prior to continuing to
the questionnaires. After consent was obtained, they completed a demographics questionnaire,
which consisted of items related to gender, age, ethnicity, weight, and height. After providing
this information, participants were presented with Rotter’s Locus of Control Scale. Next, they
completed the Rosenberg Self Esteem Questionnaire and directly following they completed the
Beck Depression Inventory. They were then presented with the Internal versus External Control
of Weight Scale; this was placed near the end of the survey so it would not affect the answers to
previous questionnaires. Lastly, the participants were given a stigma questionnaire to complete.
Although it has been suggested that obese individuals experience daily stigma, this questionnaire
was used to provide further confirmation for this sample. All questions had a “decline to answer”
option incase the participant felt uncomfortable responding to a specific question. Upon
completion, participants were shown a debriefing form (Appendix H), which addressed the true
purpose of the study and were given a code to ensure that they were compensated 50 cents for
their responses. The responses were entered into the system and analyzed using SPSS (see figure
2).
13 INFORMED
CONSENT
DEMOGRAPHICS:
GENDER
AGE
ETHNICITY
WEIGHT
HEIGHT
ROTTER’S LOCUS OF
CONTROL SCALE
ROSENBERG
SELF-ESTEEM
SCALE
BECK DEPRESSION
INVENTORY
INTERNAL VS.
EXTERNAL CONTROL
OF WEIGHT SCALE
STIGMA
EXPERIENCE
QUESTOINNAIRE
DEBRIEF
Figure 2. Order of procedure for research participants 14 RESULTS
Of the 250 study participants; 6 (2.4%) of the participants had a BMI less than 18.5,
which is considered underweight. 118 (43%) of the participants had a BMI between 18.6 and
24.9, indicating normal weight, and 126 (50.4%) of the participants where considered overweight
or obese with a BMI over 25. The means and standard deviations of BMI, LOC, depression, and
self-esteem are shown in table 1.
Table 1. Measures of central tendency and variance for BMI, locus of control, depression, and selfesteem.
Possible Range
Actual Range
Mean
SD
BMI (n=250)
17.01-44.30
25.81
5.10
LOC (n=250)
0-23
0-22
10.85
5.13
Depression (n=219) 0-57
0-37
8.25
9.56
Self-esteem (n-244) 0-40
19-32
26.27
2.03
Note: High LOC score = external locus of control; high BDI score = major depression; high selfesteem score = higher self-esteem
Prior to data analysis, the predictor variables were mean-centered to account for any
multi-colinearity between two highly correlated variables. I did this my subtracting participants
total score on both the LOC scale and the BDI by the mean score of the respective scale. The
BMI outliers were removed prior to data analysis. These participants had a BMI over 50
indicating severe obesity. Variables were normally distributed and linear relationships were
confirmed. To test the hypothesis that overweight and obese individuals with an external locus of
control would have heightened levels of depression, a multiple regression analysis was
performed. BMI, LOC, and the interaction term between BMI and LOC were entered as the
independent variables. BDI was entered as the dependent variable. There was no significant
interaction between BMI and LOC; however, the results indicate that LOC is a predictor of
depression. Results are shown in Table 2 and Figure 3.
15 Table 2. The Change in Depression as Predicted by Body Mass Index and Locus of Control.
Constant
BMI
LOC
BMI x LOC
Note: N=218; β= unstandardized coefficient. *p<.01
β
t
9.511
.153
.942
.034
6.558
1.194
3.566
1.420
p
.000
.234
.000*
.157
Figure 3. As Body Mass Index increases, participants with an
external locus of control reported higher levels of depression.
Similarly, a second multiple regression analysis was performed for exploratory purposes
to evaluate the relationship between BMI, LOC, and self-esteem. Again, BMI, LOC, and the
interaction term between BMI and LOC were entered as the independent variable. Self-esteem
was entered as the dependent variable. There was a significant interaction; the interaction
between BMI and LOC was a predictor of self-esteem (p<.01). In addition, LOC alone is a
predictor of self-esteem. Results are shown in Table 3 and Figure 4.
16 Table 3. The Change in Self-Esteem as Predicted by Body Mass Index and Locus of Control.
β
t
p
Constant
BMI
LOC
BMI x LOC
N=243; β = unstandardized coefficient. *p<.01
Note:
26.380
.009
-.171
-.013
90.093
.349
-3.070
-2.654
Figure 4. As Body Mass Index increases, participants with an external
locus of control reported significantly lower levels of self-esteem (p<.01).
.000
.727
.002*
.008*
17 Forty-six participants reported that they experienced stigma, and therefore a logistic
regression was performed to explore the effects of gender, age, BMI, and depression on the
likelihood that participants experience stigma towards obesity or body image. In addition,
interactions including BMI and age, and BMI and gender were also used to assess the likelihood
that participants experience stigma. The logistic regression model was statistically significant,
x2(4)=36.716, p<.01. The model explained 25.5% (Nagelkerke R2) of the variance in experienced
stigma and correctly classified 83.4% of cases. Sensitivity was 32.5% specificity was 96.6%,
positive predictive value was 68.4%, and the negative predictive value was 86.2%. Of the six
predictor variables, four were statistically significant: age, BMI, depression, and the interaction
between BMI and gender as shown in Table 4. Younger individuals were more likely to
experience stigma. Increased BMI and depression was associated with an increased likelihood to
experience stigma. Increased BMI and being female also increased likelihood to experience
stigma.
Table 4. Logistic Regression Predicting the Likelihood of Stigma based on Gender, Age, BMI,
and Depression.
β
SE
Exp (β)
p
CI
Lower Upper
Gender
.204
.387
1.23
.599
.574 2.619
Age
-.037
.018
1.00
.041*
.930 .998
BMI
.100
.031
1.12
.001*
1.041 1.174
Depression
.071
.018
1.10
.000*
1.037 1.113
BMI x Age
.000
.000
1.00
.905
.999 1.001
BMI x Gender
.036
.012
1.03
.003*
1.012 1.061
Note: 46 participants reported that they experienced stigma; β= unstandardized regression
coefficient, SE= standard error, Exp (β)= odds ratio, CI= Confidence interval. *p<.01
Gender is for females compared to males
18 DISCUSSION
While individuals with a high BMI and higher external locus of control was predictive of
depression, the interaction between BMI and locus of control was not significant. In addition,
participants with a high BMI and higher external locus of control significantly predicted lower
levels of self-esteem, compared to participants with a low BMI and an internal locus of control.
For both regressions, LOC predicted depression and self-esteem.
Further analyses indicated that age, BMI, depression, and the interaction between BMI
and gender significantly predicted the experience of social stigma. In this study gender alone did
not appear to be an influential factor. However, when all other variables were controlled,
females with a high BMI were 1.03 times more likely to experience stigma. In addition, younger
participants were 1.00 times more likely to experience stigma, overweight or obese participants
were 1.12 times more likely to experience stigma, and participants who reported high levels of
depression were 1.10 times more likely to experience stigma. Therefore, falling into any of these
categories heightened the likelihood of participants to experience negative societal stigma.
Published research on the relationship between obesity and depression are consistent with
this study’s findings. Individuals who are overweight or obese are more likely to suffer from
depression compared to their normal weight counterparts. Extensive research has examined the
biopsychosocial impact that obesity has on depression. For example, depression may be
influenced by a variety of behavioral factors such as physical inactivity, stress, or chronic
widespread pain (Wright et al., 2010). However, this is one of the first studies to evaluate
personality traits, being locus of control, that contribute to depression in overweight and obese
individuals.
19 Sense of control has important implications for health behavior (Steptoe & Appels,
1989). Consistent with my findings, sense of control can moderate associations between two
factors, such as obesity and overall well-being, and be responsible in part for adverse side effects
(Lachman & Weaver, 1998). Lack of control has been associated with heightened physiological
stress in humans, poor tolerance of pain, and worse mental health (Wright et al., 2010). This is
reflective of the current study. Locus of control moderates the relationship between obesity and
depression; in contrast to internals, having an external locus of control subjects obese individuals
to negative, long-term physical and mental health consequences.
In the case of depression, obese and anorexic individuals are similar. Hood, Moore, and
Garner (1982) conducted a study assessing the relationship between internal and external locus
of control in an anorexic population. They found that subjects with an external locus of control
had scores well above the mean on the Beck Depression Scale indicating greater depression.
Furthermore, Shapiro and colleagues (1993) suggest that patients with eating disorders, such as
anorexia, tend to be high externals; they have lower self-esteem and exhibit greater
psychopathology. External locus of control is a major risk factor for eating disorders. Although
studies suggest that obesity and anorexia represent opposite ends of a spectrum of eating
disorders, previous studies in accordance with the current study suggest that they share
similarities with respect to locus of control, self-esteem, and mental well-being.
As reported in previous studies, heightened rates of depression in overweight and obese
individuals may be due to stigma, which can be supported in future analyses with this dataset.
Americans hold prejudicial attitudes towards obese and overweight individuals (Puhl &
Brownell, 2001). The pervasive devaluation of individuals possessing a “discredited” personal
attribute, such as obesity, is a component of conceptualization of stigma (Goffman, 1963).
20 However, recent theories propose that stigma is a broader concept, which encompasses the
actions of social institutions, and individuals who denigrate and exclude, as well as the reactions
of persons in the devalued social category (Link & Phelan, 2001). Therefore, obese persons may
perceive that they are the target of discrimination. Their perceptions are internalized as negative
evaluations of oneself. Obese individuals believe that they have been mistreated or devalued due
to their appearance. Being treated in a discriminatory fashion, or more importantly believing that
one has been the target of discrimination due to personal attributes is an important pathway.
Individuals with an external locus of control are more likely to perceive and internalize negative
evaluations due to their social attitudes (Biondo & MacDonald, 1971). Therefore, externals
experience of depression is due in part to their negative self-perceptions.
The relationship between obesity and depression is bidirectional in nature as discussed in
the introduction. A limitation to this study is that it does not account for bidirectionality.
However, when controlling for depression at baseline, Roberts and colleagues (2002) found that
obesity predicted depression five years later. Conversely, when controlling for obesity at
baseline, depression did not predict obesity prospectively. These results indicate that obesity has
a strong prospective influence on the development of depression.
Obesity and depression are sensitive topics that often trigger humiliation and shame.
Therefore, it is possible that some of the participants may feel uncomfortable disclosing personal
information about their weight or mental status, which could result in misleading responses to
the questionnaires. On the other hand, some participants may have felt more at ease since the
questionnaires were on-line and anonymous. One of the limitations of an online, self-report study
is the inability to accurately measure weight and height. This study was dependent on the
participants’ truthful responses. If this study had been completed in person as opposed to online,
21 it would have been possible to obtain a more accurate assessment of BMI, and some participants
might have felt more comfortable disclosing information about their well-being.
This research prompts us to ask the question, what can be done for externals that are
overweight or obese and suffering from depression? How do we motivate these individuals to
seek help and make long-term mental and physical health changes when they depend heavily on
outside resources? Previous research suggests that internals respond better to self-change
programs than their external counterparts (Chapman & Jeffery, 1979; Kincey, 1980; Saltzer,
1982), due to their persistent belief that outcomes are determined by external factors such as luck
(Rotter, 1966) rather than personal control. Printed health education materials (HEM) include
generic health information—in the form of brochures, booklets, or pamphlets—designed for the
general population. These materials are often mass-produced and their one-size-fits-all approach
is not sensitive to the diverse population that influences health-related decisions and behaviors
(Kreuter et al., 1999). Therefore, HEM must be altered and tailored to a variety of individuals. In
the context of obesity, it may be more effective to utilize HEM specifically designed for those
with an internal LOC or an external LOC to account for personality differences that effect health
behavior.
The field has advanced in the identification of causal mechanisms and risk factors linking
obesity and depression. However, optimal treatment resulting in long-term psychological and
physical benefits has largely been unsuccessful. This study suggests that personality differences,
such as locus of control, should be taken into consideration in the design of an individualized
treatment strategy for weight management. To evaluate the effectiveness of such an approach
would require a randomized control trial that would compare weight management interventions
in overweight and obese individuals who have an external locus of control. Furthermore,
22 successful strategies require that we consider the negative impact of societal stigma, particularly
among obese or overweight individuals with an external locus of control. Obesity and depression
are intertwined. Thus, treatment approaches to simultaneously address depression and obesity
should be a priority for future investigations.
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30 APPENDIX A- Statement of Informed Consent
Title: Weight, Locus of Control, and Psychological Health
Principal Investigator:
Paulina Coutifaris, [email protected]
The purpose of an informed consent is to ensure that you understand the purpose of this study, the nature
of your involvement, and the conditions of your participation. It provides the information necessary for
you to make the decision concerning whether or not you wish to participate in this study. If you have any
questions or concerns while reading this form, please contact the Researcher for clarification.
Purpose: The purpose of this study is to examine the relationship between weight, locus of control and
psychological health outcomes.
Task Requirements: You will complete a set of questionnaires asking about demographic information,
locus of control, and your psychological health.
Duration and Locale: These questionnaires will take approximately 15 minutes to complete. You can
complete these questionnaires online and at your convenience.
Potential Risk/Discomfort: You may experience some discomfort answering questions about yourself.
Should this occur, you are free to decline to answer any question. You may also withdraw from this study
at any time.
Anonymity/Confidentiality: The data collected in this study are anonymous. We will not collect any
personally identifying information about you. We will not be able to link any data that you provide us
with your name or any other identifying information.
Right to Withdraw: You will be permitted to not answer any question(s) that you choose to omit. You
have the right to withdraw from this study at any time. Your participation is completely voluntary.
This project has been reviewed and approved by the Franklin & Marshall College Institutional Review
Board. Questions concerning your rights as a participant in this research may also be addressed to
Michael Billig, Ph.D., Office of the Provost, 102B, Old Main, [email protected], (717) 2914283.
☐ I understand the procedures described above, and my questions have been answered to my satisfaction.
I agree to participate in this study and am eligible to do so as I am 18 years of age or older.
31 APPENDIX B- Demographic Questionnaire
Gender:
Male
Female
Age:
Ethnicity
White
Black
Hispanic
Asian
Other
Most recently measured:
Height:
Weight:
32 APPENDIX C- Rotter’s Locus of Control Scale
For each Question select the statement that you agree with most
1. A. Children get into trouble because their parents punish them too much.
B. The trouble with most children nowadays is that their parents are too easy with them.
2. A. Many of the unhappy things in people’s lives are partly due to bad luck.
B. People’s misfortunes result form the mistakes they make.
3. A. One of the major reasons why we have wars is because people don’t take enough
interest in politics.
B. There will always be wars no matter how hard people try to prevent them.
4. A. In the long run people get the respect they deserve in this world.
B. Unfortunately, an individuals worth often passes unrecognized no matter how hard he
tries.
5. A. The idea that teachers are unfair to students is nonsense.
B. Most students don’t realize the extent to which their grades are influenced by
accidental happenings.
6. A. Without the right breaks one cannot be an effective leader.
B. Capable people who fail to become leaders have no taken advantage of their
opportunities.
7. A. No matter how hard you try some people just don’t like you.
B. People who can’t get other to like them don’t understand how to get along with others.
8. A. Heredity plays a major role in determining one’s personality.
B. It is one’s experiences in life which determine what they’re like.
9. A. I have often found that what is going to happen will happen.
B. Trusting fate has never turned out as well for me as making a decision to take a
definite course of action.
10. A. In the case of the well prepared student, there is rarely if ever such a thing as an unfair
test.
B. Many times exam questions tend to be so unrelated to course work that studying is
really useless.
11. A. Becoming a success is a matter of hard work, luck has little or nothing to do with it.
B. Getting a good job depends mainly on being in the right place at the right time.
12. A. The average citizen can have an influence in government decisions.
33 B. The world is run by the few people in power, and there is not much the little guy can
do about it.
13. A. When I make place, I am almost certain that I can make the work.
B. It is not always wise to plan too far ahead because many things turn out to be a matter
of good or bad fortune.
14. A. There are certain people who are just not good.
B. There is some good in everybody.
15. A. In my case, getting what I want has little or nothing to do with luck.
B. Many times we might just as well decide what to do by flipping a coin.
16. A. Who gets to be the boss often depends on who was lucky enough to be in the right
place first.
B. Getting people to do the right thing depends upon ability. Luck has little or nothing to
do with it.
17. A. As far as world affairs are concerned, most of us are the victims of force we can
neither understand, nor control.
B. By taking an active part in political and social affairs the people can control world
events.
18. A. Most people don’t realize the extent to which their lives are controlled by accidental
happenings.
B. There really is no such thing as ‘luck’.
19. A. One should always be willing to admit mistakes.
B. It is usually best to cover up one’s mistakes.
20. A. It is hard to know whether or not a person really like you.
B. How many friends you have depends on how nice a person you are.
21. A. In the long run, bad things that happen to us are balanced by the good ones.
B. Most misfortunes are the result of lack of ability, ignorance, laziness, or all three.
22. A. With enough effort we can wipe out political corruption.
B. It is difficult for people to have much control over the things politicians do in office.
23. A. Sometimes I can’t understand how teachers arrive at the grades they give.
B. There is a direct connection between how hard I study and the grades I get.
24. A. A good leader expects people to decide for themselves what they should do.
B. A good leader makes it clear to everybody what his or her jobs are.
34 25. A. Many times I feel that I have little influence over the things that happen to me.
B. It is impossible for me to believe that change or luck places an important role in my
life.
26. A. People are lonely because they don’t try to be friendly.
B. There’s not much use in trying too hard to please people, if they like you, they like
you.
27. A. There is too much emphasis on athletics in high school.
B. Team sports are an excellent way to build character.
28. A. What happens to me is my own doing.
B. Sometimes I feel that I don’t have enough control over the direction my life is taking.
29. A. Most of the time I cant understand why politics behave the way they do.
B. In the long run the people are responsible for bad government on a national as well as
on a local level.
35 APPENDIX D- Rosenberg’s Self-Esteem Scale
Below is a list of statements dealing with your general feelings about yourself. Please indicate
how strongly you agree or disagree with each statement.
On the whole, I am satisfied with myself.
Strongly Agree
Agree
Disagree
Strongly Disagree
At times I think I am no good at all.
Strongly Agree
Agree
Disagree
Strongly Disagree
I feel that I have a number of good qualities.
Strongly Agree
Agree
Disagree
Strongly Disagree
I am able to do things as well as most other people.
Strongly Agree
Agree
Disagree
Strongly Disagree
I feel I do not have much to be proud of.
Strongly Agree
Agree
Disagree
Strongly Disagree
I certainly feel useless at times.
Strongly Agree
Agree
Strongly Disagree
Disagree
I feel that I'm a person of worth, at least on an equal plane with others.
Strongly Agree
Agree
Disagree
Strongly Disagree
I wish I could have more respect for myself.
Strongly Agree
Agree
Disagree
Strongly Disagree
All in all, I am inclined to feel that I am a failure.
Strongly Agree
Agree
Disagree
Strongly Disagree
I take a positive attitude toward myself.
Strongly Agree
Agree
Disagree
Strongly Disagree
36 APPENDIX E- Beck Depression Inventory
0
1
2
3
I do not feel sad
I feel sad
I am sad all the time and I cant snap out of it
I am so sad and unhappy that I can’t stand it
0
1
2
3
I am not particularly discouraged about the future
I feel discouraged about the future
I feel I have nothing to look forward to
I feel the future is hopeless and that things cannot improve
0
1
2
3
I do not feel like a failure
I feel I have failed more than the average person
As I look back on my life, all I can see is a lot of failures
I feel I am a complete failure as a person
0
1
2
3
I get as much satisfaction out of things as I used to
I don’t enjoy things the way I used to
I don’t get real satisfaction out of anything anymore
I am dissatisfied or bored with everything
0
1
2
3
I don’t feel particularly guilty
I feel guilty a good part of the time
I feel quite guilty most of the time
I feel guilty all of the time
0
1
2
3
I don’t feel I am being punished
I feel I may be punished
I expect to be punished
I feel I am being punished
0
1
2
3
I don’t feel disappointed in myself
I am disappointed in myself
I am disgusted with myself
I hate myself
0
1
2
3
I don’t feel I am any worse than anybody else
I am critical of myself for my weaknesses or mistakes
I blame myself all the time for my faults
I blame myself for everything bad that happens
0
1
2
3
I don’t cry any more than usual
I cry more now than I used to
I cry all the time now
I used to be able to cry, but now I cant cry even though I want to
37 0
1
2
3
I am not more irritated by things than I ever was
I am slightly more irritated now than usual
I am quite annoyed or irritated a good deal of the time
I feel irritated all the time
0
1
2
3
I have not lost interest in other people
I am less interested in other people than I used to be
I have lost most of my interest in other people
I have lost all my interest in other people
0
1
2
3
I make decisions about as well as I ever could
I put off making decisions more than I used to
I have greater difficulty in making decisions more than I used to
I cant make decisions at all anymore
0
1
2
3
I don’t feel that I look any worse than I used to
I am worried that I am looking old or unattractive
I feel there are permanent changes in my appearance that make me look unattractive
I believe that I look ugly
0
1
2
3
I can work about as well as before
It takes an extra effort to get started at doing something
I have to push myself very hard to do anything
I cant do any work at all
0
1
2
3
I can sleep as well as usual
I don’t sleep as well as I used to
I wake up 1-2 hours earlier than usual and find it hard to get back to sleep
I wake up several hours earlier than I used to and cannot get back to sleep
0
1
2
3
I don’t get more tired than usual
I get tired more easily than I used to
I get tired from doing almost anything
I am too tired to do anything
0
1
2
3
I am not more worried about my health than usual
I am worried about physical problems like aches, pains, upset stomach, or
constipation
I am very worried about physical problems and its hard to think of much else
I am so worried about my physical problems
0
1
2
3
I have not noticed any recent change in my interest in sex
I am less interested in sex than I used to be
I have almost no interest in sex
I have lost interest in sex completely
38 APPENDIX F- Internal versus External Control of Weight Scale (IECW)
1. ☐Overweight problems are mainly a result of hereditary or physiological factors
☐Overweight problems are mainly a result of lack of self-control
2. ☐Overweight people will lose weight only when they can generate enough internal
motivation
☐Overweight people need some tangible external motivation in order to reduce
3. ☐Diet pills can be a valuable aid in weight reduction
☐A person who loses weight with diet pills will gain the weight back eventually
4. ☐In overweight people, hunger is caused by the expectation of being hungry
☐in overweight people, hunger is caused by stomach contractions and low blood sugar
levels
5. ☐Overweight problems can be traced to early childhood and are very resistant to change
☐Overweight problems can be traced to poor eating habits, which are relatively simple to
change
39 APPENDIX G- Stigma Questionnaire
1. Do you experience stigma based on weight or body image?
Yes
No
Decline to Answer
2. Do you feel the stigma reflects negatively on yourself?
Strongly Disagree
Disagree
Agree
Strongly Agree
3. Do you feel the stigma reflects negatively on society?
Strongly Disagree
Disagree
Agree
Strongly Agree
40 APPENDIX H- Debriefing Form
How Does Stigma Influence One’s Perception of Obesity? The Relationship Between Obesity,
Locus of Control, and Depression
Given the sharp increase in obesity in the United States, I was interested in understanding the
relationship between obesity and mental health. While the association between obesity and
depression has been extensively studied, I was looking at the way in which personality factors,
and in this case locus of control, may promote the onset of depression in an obese population.
With the ongoing negative stigma that obese individuals endure, locus of control orientation may
place one at risk of internalizing negative stigma, and developing depression. In order to study
this relationship, each participant was asked to provide me with his or her weight and height,
complete a variety of questionnaires regarding locus of control orientation, depression, and the
internalization of stigma.
I hypothesize that those with an external locus of control will be more vulnerable and internalize
society’s negative stigma towards obesity, and thus, interpret obesity as a negative entity
attributed to their identity. In addition, this process will provoke depressive symptomology.
Therefore, obese individuals with an external locus of control will report greater depressive
symptomology as opposed to those with an internal locus of control.
While research has identified biological, psychological, and social factors that contribute to the
onset of depression in obese people, there is little research on personality differences that may
promote the onset of depression in obese people. Therefore, the goal of this research is to
identify the role of a personality factor (locus of control) in the development of depression in
obese individuals.
Thank you for participating! Please do not discuss this debriefing with any other potential
participants!
If you have any questions, comments, or concerns please feel free to email or call the contact
below.
Researcher: Paulina Coutifaris; [email protected]
Faculty Advisor Sponsor: Allison Troy; [email protected] (717) 291-3833
Christina Abbott; [email protected] (717) 358-58
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