Mediated effects of eating disturbances in the association of perceived weight stigma and emotional distress

  • Chung-Ying LinEmail author
  • Carol Strong
  • Janet D. Latner
  • Yi-Ching Lin
  • Meng-Che Tsai
  • Pauline Cheung
Original Article



This study aimed to examine the relationships between perceived weight stigma, eating disturbances, and emotional distress across individuals with different self-perceived weight status.


University students from Hong Kong (n = 400) and Taiwan (n = 307) participated in this study and completed several questionnaires: Perceived Weight Stigma questionnaire; Three-factor Eating Questionnaire; Hospital Anxiety and Depression Scale. Each participant self-reported their height, weight, and self-perceived weight status.


After controlling for demographics, perceived weight stigma was associated with eating disturbances (β = 0.223, p < 0.001), depression (β = 0.143, p < 0.001), and anxiety (β = 0.193, p < 0.001); and eating disturbances was associated with depression (β = 0.147, p < 0.001) and anxiety (β = 0.300, p < 0.001) in the whole sample. Additionally, eating disturbances mediated the association between perceived weight stigma and emotional distress. Similar findings were shown in the subsamples who perceived themselves as higher weight or normal weight and in the male and female subsamples. However, in the subsamples who perceived themselves as lower weight, only the links between eating disturbances and emotional distress were significant.


Perceived weight stigma was associated with eating disturbances and emotional distress in young adults with both higher and normal weight. Eating disturbances were associated with emotional distress regardless of participants’ weight status.

Level of evidence

Level V, cross-sectional descriptive study.


Asian Anxiety Depression Eating behaviors Weight bias 



This research was supported in part by (received funding from) the startup fund in the Department of Rehabilitation Sciences, the Hong Kong Polytechnic University, Hong Kong. The authors have no financial relationships relevant to this article to disclose.

Compliance with ethical standards

Conflict of interest

The authors have no conflicts of interest to disclose.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Supplementary material

40519_2019_641_MOESM1_ESM.docx (15 kb)
Supplementary material 1 (DOCX 14 KB)


  1. 1.
    Brisbois TD, Farmer AP, McCargar LJ (2012) Early markers of adult obesity: a review. Obes Rev 13(4):347–367. Google Scholar
  2. 2.
    Lin C-Y (2019) Ethical issues of monitoring children’s weight status in school settings. Social Health Behav 2(1):1–6. Google Scholar
  3. 3.
    Lin C-Y, Su C-T, Wang J-D, Ma H-I (2013) Self-rated and parent-rated quality of life (QoL) for community-based obese and overweight children. Acta Paediatr 102:e114–e119. Google Scholar
  4. 4.
    Lin Y-C, Latner JD, Fung XCC, Lin C-Y (2018) Poor health and experiences of being bullied in adolescents: Self-perceived overweight and frustration with appearance matter. Obesity 26:397–404. Google Scholar
  5. 5.
    Lorem GF, Schirmer H, Emaus N (2017) What is the impact of underweight on self-reported health trajectories and mortality rates: a cohort study. Health Qual Life Outcomes 15(1):191. Google Scholar
  6. 6.
    Skinner AC, Perrin EM, Skelton JA (2016) Prevalence of obesity and severe obesity in US children, 1999–2014. Obesity 24(5):1116–1123. Google Scholar
  7. 7.
    Meadows A, Daníelsdóttir S (2016) What’s in a word? On weight stigma and terminology. Front Psychol 7:1527. Google Scholar
  8. 8.
    Puhl RM, Heuer CA (2009) The stigma of obesity: a review and update. Obesity 17:941–964. Google Scholar
  9. 9.
    Myers A, Rosen JC (1999) Obesity stigmatization and coping: relation to mental health symptoms, body image, and self-esteem. Int J Obes 23:221–230Google Scholar
  10. 10.
    O’Brien KS, Latner JD, Puhl RM, Vartanian LR, Giles C, Griva K, Carter A (2016) The relationship between weight stigma and eating behavior is explained by weight bias internalization and psychological distress. Appetite 102:70–76. Google Scholar
  11. 11.
    Pearl RL, White MA, Grilo CM (2014) Weight bias internalization, depression, and self-reported health among overweight binge eating disorder patients. Obesity 22(5):E142–E148. Google Scholar
  12. 12.
    Cheng MY, Wang S-M, Lam YY, Luk HT, Man YC, Lin C-Y (2018) The relationships between weight bias, perceived weight stigma, eating behavior and psychological distress among undergraduate students in Hong Kong. J Nerv Ment Dis 206:705–710. Google Scholar
  13. 13.
    Essayli JH, Murakami JM, Wilson RE, Latner JD (2017) The impact of weight labels on body image, internalized weight stigma, affect, perceived health, and intended weight loss behaviors in normal-weight and overweight college women. Am J Health Promot 31(6):484–490. Google Scholar
  14. 14.
    Wong PC, Hsieh Y-P, Ng HH, Kong SF, Chan KL, Au TYA, Lin C-Y, Fung XCC (2018) Investigating the self-stigma and quality of life for overweight/obese children in Hong Kong: a preliminary study. Child Ind Res Adv Online Publ. Google Scholar
  15. 15.
    Ashmore JA, Friedman KE, Reichmann SK, Musante GJ (2008) Weight-based stigmatization, psychological distress, & binge eating behavior among obese treatment-seeking adults. Eat Behav 9(2):203–209. Google Scholar
  16. 16.
    Schvey NA, White MA (2015) The internalization of weight bias is associated with severe eating pathology among lean individuals. Eat Behav 17:1–5. Google Scholar
  17. 17.
    Pearl RL, Puhl RM (2018) Weight bias internalization and health: a systematic review. Obes Rev 19(8):1141–1163. Google Scholar
  18. 18.
    Palmeira L, Cunha M, Pinto-Gouveia J (2018) The weight of weight self-stigma in unhealthy eating behaviours: the mediator role of weight-related experiential avoidance. Eat Weight Disord 23(6):785–796. Google Scholar
  19. 19.
    Hudson JI, Hiripi E, Pope HG Jr, Kessler RC (2007) The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biol Psychiatry 61:348–358. Google Scholar
  20. 20.
    Grilo CM, White MA, Masheb RM (2009) DSM-IV Psychiatric disorder comorbidity and its correlates in binge eating disorder. Int J Eat Disord 42:228–234. Google Scholar
  21. 21.
    Salwen JK, Hymowitz GF, Bannon SM, O’Leary KD (2015) Weight-related abuse: perceived emotional impact and the effect on disordered eating. Child Abuse Negl 45:163–171. Google Scholar
  22. 22.
    Vartanian LR (2015) Development and validation of a brief version of the stigmatizing situations inventory. Obes Sci Pract 1:119–125. Google Scholar
  23. 23.
    Gan WY, Mohd Nasir MT, Zalilah MS, Hazizi AS (2011) Direct and indirect effects of sociocultural influences on disordered eating among Malaysian male and female university students. A mediation analysis of psychological distress. Appetite 56(3):778–783. Google Scholar
  24. 24.
    Duncan DT, Ding EL, Warner ET, Bennett GG, Wolin KY, Scharoun-Lee M (2011) Does perception equal reality? Weight misperception in relation to weight-related attitudes and behaviors among overweight and obese US adults. Int J Behav Nutr Phys Act 8(1):20. Google Scholar
  25. 25.
    Isomaa R, Isomaa AL, Marttunen M, Kaltiala-Heino R, Björkqvist K (2010) Psychological distress and risk for eating disorders in subgroups of dieters. Eur Eat Disord Rev 18:296–303. Google Scholar
  26. 26.
    Isomaa R, Isomaa AL, Marttunen M, Kaltiala-Heino R, Björkqvist K (2011) Longitudinal concomitants of incorrect weight perception in female and male adolescents. Body Image 8:58–63. Google Scholar
  27. 27.
    Lee S, Leung T, Lee AM, Yu H, Leung CM (1996) Body dissatisfaction among Chinese undergraduates and its implications for eating disorders in Hong Kong. Int J Eat Disord 20(1):77–84.;2-1 Google Scholar
  28. 28.
    Mak KK, Lai CM (2011) The risks of disordered eating in Hong Kong adolescents. Eat Weight Disord 16(4):e289–e292. Google Scholar
  29. 29.
    Miri SF, Javadi M, Lin C-Y, Irandoost K, Rezazadeh A, Pakpour AH (2017) Health related quality of life and weight self-efficacy of life style among normal-weight, overweight and obese Iranian adolescents: a case control study. Int J Pediatr 5(11):5975–5984. Google Scholar
  30. 30.
    Himmelstein MS, Puhl RM, Quinn DM (2017) Intersectionality: an understudied framework for addressing weight stigma. Am J Prev Med 53(4):421–431. Google Scholar
  31. 31.
    Wong Y, Huang YC (1999) Obesity concerns, weight satisfaction and characteristics of female dieters: a study on female Taiwanese college students. J Am Coll Nutr 18(2):194–200. Google Scholar
  32. 32.
    Schafer MH, Ferraro KF (2011) The stigma of obesity: does perceived weight discrimination affect identity and physical health? Soc Psychol Q 74(1):76–97. Google Scholar
  33. 33.
    Williams DR, Yu Y, Jackson JS, Anderson NB (1997) Racial differences in physical and mental health: Socioeconomic status, stress, and discrimination. J Health Psychol 2:335–351. Google Scholar
  34. 34.
    De Lauzon B, Romon M, Deschamps V et al (2004) The three-factor eating questionnaire-R18 is able to distinguish among different eating patterns in a general population. J Nutr 134(9):2372–2380. Google Scholar
  35. 35.
    Stunkard AJ, Messick S (1985) The three-factor eating questionnaire to measure dietary restraint, disinhibition and hunger. J Psychosom Res 29(1):71–83. Google Scholar
  36. 36.
    Lin C-Y, Pakpour AH (2017) Using Hospital Anxiety and depression scale (HADS) on patients with epilepsy: confirmatory factor analysis and Rasch models. Seizure 45:42–46. Google Scholar
  37. 37.
    Mykletun A, Stordal E, Dahl AA (2001) Hospital Anxiety and Depression (HAD) scale: factor structure, item analyses and internal consistency in a large population. Br J Psychiatry 179:540–544. Google Scholar
  38. 38.
    Yam C-W, Pakpour AH, Griffiths MD, Yau W-Y, Lo C-LM, Ng JMT, Lin C-Y, Leung H (2018) Psychometric testing of three Chinese online-related addictive behavior instruments among Hong Kong university students. Psychiatr Q. Google Scholar
  39. 39.
    Lin C-Y (2018) Comparing quality of life instruments: sizing them up versus PedsQL and Kid-KINDL. Social Health Behav 1(2):42–47. Google Scholar
  40. 40.
    Pakpour AH, Chen C-Y, Lin C-Y, Strong C, Tsai M-C, Lin Y-C (2019) The relationship between children’s overweight and quality of life: a comparison of Sizing Me Up, PedsQL, and Kid-KINDL. Int J of Clin Health Psychol 19(1):49–56. Google Scholar
  41. 41.
    Chang C-C, Su J-A, Chang K-C, Lin C-Y, Koschorke M, Thornicroft G (2018) Perceived stigma of caregivers: psychometric evaluation for devaluation of consumer families scale. Int J Clin Health Psychol 18(2):170–178. Google Scholar
  42. 42.
    Lin C-Y, Ku L-JE, Pakpour AH (2017) Measurement invariance across educational levels and gender in 12-Item Zarit Burden Interview (ZBI) on caregivers of people with dementia. Int Psychogeriatr 29(11):1841–1848. Google Scholar
  43. 43.
    Puhl R, Suh Y (2015) Health consequences of weight stigma: Implications for obesity prevention and treatment. Curr Obes Rep 4(2):182–190. Google Scholar
  44. 44.
    Haines J, Neumark-Sztainer D, Eisenberg ME, Hannan PJ (2006) Weight teasing and disordered eating behaviors in adolescents: Longitudinal findings from project EAT (eating among teens). Pediatrics 117:209–215. Google Scholar
  45. 45.
    Zucker N, Copeland W, Franz L, Carpenter K, Keeling L, Angold A, Egger H (2015) Psychological and psychosocial impairment in preschoolers with selective eating. Pediatrics 136(3):e582–e590. Google Scholar
  46. 46.
    Wiseman CV, Gray JJ, Mosimann JE, Ahrens AH (1992) Cultural expectations of thinness in women: an update. Int J Eat Disord 11:85–89.;2-T Google Scholar
  47. 47.
    Marini M (2017) Underweight vs. overweight/obese: which weight category do we prefer? Dissociation of weight-related preferences at the explicit and implicit level. Obes Sci Pract 3:390–398. Google Scholar
  48. 48.
    Himmelstein MS, Puhl RM, Quinn DM (2018) Weight stigma in men: What, when, and by whom? Obesity (Silver Spring) 26(6):968–976. Google Scholar
  49. 49.
    Tao ZL, Liu Y (2009) Is there a relationship between internet dependence and eating disorders? A comparison study of internet dependents and non-internet dependents. Eat Weight Disord 14:e77–e83. Google Scholar
  50. 50.
    Alpaslan AH, Kocak U, Avci K, Uzel Tas H (2015) The association between internet addiction and disordered eating attitudes among Turkish high school students. Eat Weight Disord 20:441–448. Google Scholar
  51. 51.
    Strong C, Lee C-T, Cha L-H, Lin C-Y, Tsai M-C (2018) Adolescent internet use, social integration, and depressive symptoms: analysis from a longitudinal cohort survey. J Dev Behav Pediatr 39:318–324. Google Scholar
  52. 52.
    Griffiths MD (2018) Five myths about gaming disorder. Soc Health Behav 1:2–3. Google Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Department of Rehabilitation Sciences, Faculty of Health and Social SciencesThe Hong Kong Polytechnic UniversityHung HomHong Kong
  2. 2.Department of Public Health, National Cheng Kung University Hospital, College of MedicineNational Cheng Kung UniversityTainanTaiwan
  3. 3.Department of PsychologyUniversity of Hawaii at ManoaHonoluluUSA
  4. 4.Department of Early Childhood and Family Education, College of EducationNational Taipei University of EducationTaipeiTaiwan
  5. 5.Department of Pediatrics, National Cheng Kung University Hospital, College of MedicineNational Cheng Kung UniversityTainanTaiwan

Personalised recommendations