Current research suggests that stigmatization based on weight or size in children and adolescents is prevalent and possibly increasing (1). Stigmatization carries risks for reduced emotional and possibly physical health (1). Given the increase in levels of overweight and obesity among children and adolescents over the past several decades (2), weight stigmatization has the potential to negatively affect a substantial number of children and adolescents.
To date, little is known about the prevalence of weight stigmatization across race and ethnicity in youth (1). There have been suggestions in the literature that standards of attractiveness or of acceptable body size may differ across racial groups. For instance, several researchers have found that African-American adults have different body size preferences or ideals than white adults (3,4). It might thus be expected that the degree of weight stigmatization might differ as well. In fact, Latner et al. (5) found that among university students, African-American women held more favorable attitudes toward obese individuals than did white or African-American men. However, other studies have not found such differences across race. For instance, Akan and Grilo (6) found that reported rates of weight-based teasing did not differ between white and African-American college students of average weight, but Asian-American students reported less teasing. Greenleaf et al. (7) likewise found no difference in weight-based stereotypes between Hispanic and white adolescents, although the authors noted that power for this comparison in their study was low. An interview study with overweight African-American and white adolescent girls also found little evidence of fewer experiences of stigma in the African-American girls (8). In a recent review of weight stigmatization in children, Puhl and Latner (1) note the conflicting findings regarding race/ethnicity and stigmatization, as well as the overall paucity of such research, and suggest that "stratified sampling methods are needed to compare the influence of ethnicity across sex, age, and various weight categories" (p. 561).
Weight stigmatization can be experienced in a variety of ways. The most commonly examined manifestations of experienced stigmatization in children and adolescents include verbal teasing, physical bullying, and relational victimization such as social exclusion or rejection (1). Teasing about weight has been investigated in numerous studies, and has been found to be associated with multiple negative outcomes. Previous studies have documented associations between being the victim of weight teasing and body dissatisfaction, low self-esteem, depressive symptoms, and problematic eating behaviors (9,10,11,12,13). As might be expected, weight teasing is generally reported more often among overweight and obese adolescents and children than among those who are of normal weight. For instance, a previous study by our research team (14) found that weight teasing in general, and weight teasing by peers and family members, increased across weight status from normal weight to very overweight. In a longitudinal study, Griffiths et al. (15) reported that obese elementary school girls and boys, but not overweight girls or boys, were more likely than children of normal weight to later be victims of "overt bullying," which included teasing.
However, as with the literature on weight stigmatization overall, there has been relatively little research on weight teasing in nonwhite groups. Not much is known about the rates of teasing within different minority groups, especially stratified by gender and weight status. In a previous study with the same sample used in the current study, we examined the prevalences of weight teasing across race among a combined group of overweight and obese adolescents, and found few significant differences by race/ethnicity (14). However, we did not distinguish between overweight and obese adolescents, and we did not include average-weight adolescents, in our comparisons across race/ethnicity. Further, we did not address the effects of the teasing.
To address the gaps in the literature regarding race and weight stigmatization, the current study examines the prevalence of three types of teasing (weight teasing in general, from family, and from peers) in a large, racially, ethnically, and socioeconomically diverse sample of adolescent boys and girls. In addition to weight teasing itself, we also examine the degree to which adolescents were bothered by the teasing they experienced from family and peers. We examine prevalences for adolescents who reported they are white, black, Hispanic or Latino, Asian-American, or "other", which included Native American, Hawaiian-Pacific Islander, and mixed race/ethnicity. In addition, we report results stratified by weight status as well as race and gender.
Method
Study design
Data for the present study were drawn from Project EAT (Eating Among Teens), a prospective study examining eating and weight-related behaviors in a large, ethnically and racially diverse sample of adolescents. Only the first wave of data is used in the current study. On two occasions during their Health, Physical Education, or Science class, students completed surveys under the direction of trained research staff. Height and weight were assessed by research staff within a private area in the school, generally on the second day of survey administration. Study procedures were approved by the University of Minnesota Human Subjects' committee and by the research boards of the participating school districts. Consent procedures were in accordance with the requests of the participating school districts; in some schools passive consent procedures were utilized whereas in others active consent procedures were required. The response rate for student participation was 81.5%, and the primary reasons for lack of participation were absenteeism and failure to return consent forms in schools requiring active consent. Further details regarding the study design are available elsewhere (16,17).
Study population
Participants included 4,746 adolescents drawn from 31 public middle schools and high schools in the St Paul-Minneapolis area of Minnesota. Both males (50.2%) and females (49.8%) were included, and the mean age of the adolescents was 14.9 years (s.d. = 1.7). Approximately one-third of participants (34%) were in middle school, and two-thirds were in high school (66%). The racial/ethnic background of the participants was as follows: 48.5% white, 19.0% African American or black, 19.2% Asian American, 5.8% Hispanic, 3.5% Native American, and 3.9% mixed or other.
Survey development
The entire project EAT survey is a 221-item epidemiological survey assessing a wide range of socioenvironmental, personal, and behavioral factors of potential relevance to weight, nutritional health, and physical activity among adolescents. Empirical data collected in 21 focus groups of adolescents (17) and a theoretical framework (Social Cognitive Theory (18)) guided the selection of constructs to be assessed in the survey. Whenever possible, previously validated scales were used. In cases in which suitable questions were not available, existing questions were modified to meet the needs of the study or new questions were developed. Items were selected on the basis of their potential to guide school and community intervention development. The survey went through multiple revisions based on input from a team of experts from diverse professional backgrounds, members of the University of Minnesota Youth Advisory Board, and piloting with groups of 7th and 10th grade students (16,19). More detailed information regarding the specific measures used in the current study appears below.
Measures
Weight status was based on height and weight measurements taken by trained research staff, using standardized equipment and procedures. Stature and weight were measured without shoes and wearing light indoor clothing. Height was measured with a portable stadiometer using the Frankfort Plane Technique. Weight was measured using a portable digital scale that was calibrated with a certified fifty pound weight each time the scale was moved. Research staff collecting anthropometric measurements were trained and evaluated by a senior project staff member before conducting any measurements of participants, and were regularly recertified. Quality control checks were conducted monthly at the school sites. BMI values were calculated according to the formula: weight (kg)/height (m)2. Using gender- and age-specific cut-points based on reference data from the Centers for Disease Control growth charts, respondents were classified as underweight (BMI <15th percentile), average weight (BMI 15th percentile to <85th percentile), overweight (BMI 85th to <95th percentile), and obese (BMI 
95th percentile) (20).[1] Numbers of underweight participants were too small to include in stratified analyses, but the underweight participants were included in overall analyses of the entire sample of boys and girls. Of the total sample of 4,746 participants who completed surveys, 494 had missing data on BMI. Four-hundred students were absent from class on the day height and weight were measured, and 40 students refused measurements.
Several items were used to assess weight teasing. Participants indicated how often "you are teased about your weight," with five possible responses ranging from "never" to "at least once a week." The distribution of this variable was nonnormal, and when stratified by race and gender frequencies became small, so responses were dichotomized into "never" vs. "ever been teased" (all other responses). Weight teasing by peers was assessed with the question: "Have you ever been teased or made fun of by other kids because of your weight?" (yes/no). A similar question assessed weight teasing by family members. Participants also reported the degree to which they were bothered by the weight teasing by their peers or family members, on a 4-point scale ranging from "not at all" to "very much". These questions were developed using the frequency and effect response options used in a previously validated questionnaire on weight teasing (22). The "bothered" questions were dichotomized into "not at all/a little bit" and "somewhat/very much," as we have done previously (14).
Gender and race/ethnicity were reported by participants. Race/ethnicity was assessed with the question: "Do you think of yourself as; (i) white; (ii) black or African- American; (iii) Hispanic or Latino; (iv) Asian-American; (v) Hawaiian or Pacific Islander; or (vi) American Indian or Native American." Youths were given the option of choosing multiple responses and those reporting more than one response were coded as "mixed/other race." Because of the small number of youth reporting "Hawaiian or Pacific Islander" and "American Indian or Native American," these participants were coded as "mixed/other race."
Data analysis
Based on a priori findings of gender differences in teasing (14), all analyses were stratified by gender. Associations between race and the (i) general, (ii) peer, and (iii) family teasing variables, overall and stratified by weight status category, were examined using 
2-tests of independence. Logistic regressions were conducted to examine whether there were significant differences between race/ethnicity groups overall and within weight status, using whites as the reference group. Logistic regressions were also used to examine whether teasing prevalence for overweight and obese adolescents differed from the prevalence among average-weight adolescents, within race/ethnicity group. Among youth who reported being teased by peers or family members, percentages reporting that the teasing bothered them were examined across weight status using 2-tests and logistic regression to compare all other race/ethnicity groups to whites. As the focus of this study is on the prevalence of weight teasing across subgroups of the population, percentages are reported and P values from logistic regressions provided, in lieu of odds ratios and confidence intervals. SAS 9.1 was used to conduct all analyses (23).
Results
Overall teasing
Overall 42.9% of adolescent girls in the sample reported being teased about their weight, with percentages ranging from 41.0 to 45.7% across the different race/ethnicity subgroups (Table 1). The differences in prevalence across race/ethnicity were not significant (P = 0.73). In adolescent boys, the prevalence of reported weight teasing was 35.3% overall, with percentages for individual race/ethnicity groups ranging from 32.1 to 41.0%. As with the girls, there was no significant difference across race/ethnicity category among the boys (P = 0.42).
Table 1 - Percent of adolescents who reported ever being teased about their weight, by race/ethnicity and gender.
Full table (19K)Stratifying by weight status, results were similar (Table 2). For average-weight and overweight girls and boys, there were no significant racial/ethnic differences in teasing. Some prevalences appear to differ substantially, but further inspection reveals that these are generally found in cells with relatively low numbers. Among obese adolescents, Asian-American and mixed/other adolescent girls and black boys were significantly less likely than other racial groups to report having been teased.
Table 2 - Percent of adolescents who reported ever being teased about their weight, by race/ethnicity, gender and weight status.
Full table (44K)Weight teasing by peers
Regarding teasing by peers, there was a significant (P = 0.01) difference across race/ethnicity in adolescent girls (Table 3). Asian-American girls reported significantly less peer teasing than white girls. There was also a significant (P = 0.006) difference in peer teasing across race/ethnicity in boys. Asian-American and black boys reported less peer teasing than white boys, and Hispanic boys also had a lower prevalence than whites, but not significantly so, which is probably because of their lower sample size. No other comparisons were statistically significant.
Table 3 - Percent of adolescents who reported ever being teased about weight by their peers, by race/ethnicity and gender.
Full table (18K)Stratifying by weight status, only a few differences were significant (Table 4). A greater percentage of mixed/other average-weight girls reported teasing, compared to the white average-weight girls. In addition, overweight black and obese Asian-American girls reported less peer teasing than other race/ethnicity groups in the same weight status. Among boys, average-weight Hispanic and average-weight and obese Asian-American adolescents had significantly lower prevalences of peer teasing than white adolescents in the same weight status.
Table 4 - Percent of adolescents who reported ever being teased about weight by their peers, by race/ethnicity, gender and weight status.
Full table (44K)Weight teasing by family member
Weight teasing by family members showed significant differences across race/ethnicity in adolescent girls (P < 0.001), with significantly more Hispanic, Asian-American, and mixed/other girls reporting weight teasing by family members, compared to whites (Table 5). White and black girls did not differ significantly. There were no significant differences across race in reported family weight teasing among boys (P = 0.39).
Table 5 - Percent of adolescents who reported ever being teased about weight by their family, by race/ethnicity and gender.
Full table (18K)When stratified by weight status, prevalences among the average-weight girls mirrored those in overall analyses. Asian-American and mixed/other average-weight girls reported higher prevalences of family weight teasing than white average-weight girls (Table 6). Hispanic average-weight girls had a prevalence that was also higher than their white counterparts, but not significantly so, which is possibly because of lower power for this particular comparison. The only significant difference among boys was for overweight Asian-American boys, who reported significantly more family teasing than white overweight boys.
Table 6 - Percent of adolescents who reported ever being teased about weight by their family, by race/ethnicity, gender and weight status.
Full table (43K)Prevalences among overweight and obese vs. average-weight adolescents
Comparisons of the prevalence of teasing among overweight adolescents vs. average-weight adolescents, and obese adolescents vs. average-weight adolescents, were conducted for all three teasing variables. In nearly all race/ethnicity groups of both genders, obese adolescents were significantly and substantially more likely to report being teased than were average-weight adolescents; exceptions to this pattern occurred only in groups with very low numbers (n < 30). In some racial/ethnic groups of boys and girls, overweight adolescents also had significantly higher prevalences of teasing than average-weight adolescents. However, no pattern was discernible by race, gender, or type of teasing.
Degree to which adolescents were bothered by teasing by peers and family members
Among adolescents who had been teased by their peers or family members, the degree to which adolescents were bothered by this teasing "somewhat" or "very much" was significantly different across race/ethnicity for girls but not for boys (Table 7). Significantly fewer black and mixed/other girls were bothered by peer weight teasing and family weight teasing, compared to white girls. In addition, significantly fewer Asian-American girls than white girls were bothered by family weight teasing. The prevalence of being bothered by family weight teasing in Hispanic girls was lower in absolute value than all other racial/ethnic groups of girls, but was not significantly different from white girls, probably because of the small number of Hispanic participants.
Table 7 - Number of adolescents who reported ever being teased about weight by their peers and family members, and percent of teased adolescents who were bothered by the teasing, by race/ethnicity and gender.
Full table (32K)Discussion
The current study investigated whether there are differences across race/ethnicity in the prevalence of weight-related teasing in general, as well as weight-related teasing by peers and by family members, in adolescent boys and girls. Prevalences of teasing stratified by weight status were also examined across race/ethnicity. In addition, the degree to which teased adolescents were bothered by the weight teasing they received from their peers and family members was also examined. In the most general terms, our findings indicate that many adolescents, regardless of race, report concerning levels of weight teasing, with increases across weight status. Focusing on ethnic/racial groups that showed significant differences in more than one weight stratum, it appears that adolescents of various racial/ethnic groups are reporting similar levels of weight teasing when the source of teasing is unspecified; that Asian-American adolescents, especially boys, report less peer weight teasing than white adolescents; and that Asian-American, Hispanic, and mixed/other girls report higher levels of family weight teasing compared to white girls. Interestingly, adolescent girls showed large differences across race/ethnicity in how much they were bothered by weight teasing by peers and family members. Black and mixed/other adolescent girls were less bothered by the peer teasing and family teasing than were whites, and Asian-American girls were less bothered by family teasing than whites.
Our findings regarding weight teasing in general correspond with those of Akan and Grilo (6) in that we also found no significant difference between black and white adolescent girls' reports of overall weight teasing. We did find that obese Asian-American girls reported lower rates of general teasing, but not normal weight Asian-American girls, which contrasts with Akan and Grilo's findings. We are unclear why it might be that Asian-American adolescents might be reporting less teasing, both overall and peer teasing, and thus this finding merits further investigation. Regarding differences across weight status, our findings of increased prevalences of teasing in obese adolescents, regardless of race, are in accord with other studies (15). It appears that no matter what racial/ethnic group an adolescent belongs to, he or she is probably more at risk for weight teasing if overweight, and is at extremely high risk for being teased about weight if obese.
The results of the current study suggest that weight-based teasing is a problem for all youth, and especially so for overweight and obese youth, regardless of racial/ethnic group. It appears that Asian-American adolescents, especially boys, may experience somewhat less weight teasing from peers, and possibly more teasing from family members. However, even though average-weight Asian-American boys' reported experience of peer weight teasing was nearly the lowest prevalence of all groups of any kind of teasing, still more than 1 in 20 reported peer weight teasing. These results might be taken as one indication of the pervasiveness of experienced weight stigmatization among youth, both in general and from adolescents' peers and their families.
Furthermore, the teasing these adolescents experienced was troublesome to them, as evidenced by the fact that one-quarter to one-half of those teased were bothered by it. It appears that white adolescent girls are more bothered by teasing, especially by their family members, than girls in other racial/ethnic groups. It is possible that differences in emotional responses to teasing, rather than in the prevalence of teasing itself, are more important in understanding racial/ethnic differences in teasing, and may have more implications for negative consequences. Another possibility is that the teasing itself differs across race, perhaps in its intensity or in whether it is more affiliative or malicious (24). This finding should be replicated, and if corroborated, future studies might examine these hypotheses more closely.
Several strengths of the current study provide support for the validity of our conclusions. Substantial numbers of participants in several nonwhite racial/ethnic groups participated in this study, allowing us to examine racial/ethnic differences overall and stratified by weight status. Weight teasing in general, by peers, and by family members were examined, which provides a more complete picture of the teasing from multiple sources experienced by the participants. Finally, the degree to which adolescents were bothered by the weight teasing they experienced was also examined, allowing us to draw conclusions regarding whether different racial/ethnic groups may have different emotional responses to weight teasing. Several weaknesses should also be considered when interpreting the findings of the current study. The use of single-item indicators of the constructs studied may have reduced the reliability and validity of the measurements. Also, it may be that the term "teased" is interpreted differently across race/ethnicity or that different types of weight teasing occur across race/ethnicity. Furthermore, the current study concerns only one type of experienced stigmatization, teasing, and there may be racial/ethnic differences in other types of weight stigmatization that were not captured in this study, such as exclusion from social activities, less direct verbal feedback such as comments made as "helpful" suggestions about weight that are actually hurtful, and physical bullying. In addition, although the overall sample size and the numbers of nonwhite participants were large, for some racial/ethnic groups there may not have been adequate sample size to detect differences in stratified analyses. Thus, our null findings in stratified analyses especially need to be replicated.
Future studies of racial/ethnic differences in weight stigmatization should try to unravel the conflict between studies of adults that have suggested that black women may be more accepting of overweight among themselves and others (3,4), and the current study that indicates that differences between black girls and other girls are rare. It is possible, for instance, that black adolescents' views of attractiveness correspond more to the dominant group's social norms, whereas adult women's views may be more in line with subcultural norms. It is also possible that there is an effect of region in our data. Minnesota's population is 90% white (25), and it is possible that social norms for body size among blacks in Minnesota align more closely with whites' than in regions with a larger black population.
The current study provides, to our knowledge, the most comprehensive findings to date on racial and ethnic differences in experienced weight teasing in youth. Implications of these findings for clinicians who deal with overweight and obese youth are that no assumptions should be made regarding experienced stigmatization based on a youth's racial/ethnic group. This study provides support for those clinicians who already assume that weight teasing has been experienced by many of their obese, and even overweight, patients. The high prevalences of weight teasing in all racial/ethnic subgroups of adolescents found in the current study, in conjunction with strong associations between weight teasing and negative outcomes among children and adolescents previously described in the literature (26), suggest that efforts to eradicate weight stigmatization would provide benefits to a sizable number of adolescents across a variety of racial and ethnic groups.
Notes
[1]Note: At the time of the study, the accepted terms were "at-risk for overweight" and "overweight" for the last two groups. Although we have our qualms about the more recently adopted terms of overweight and obesity (21), the terms are being used in the literature and thus will also be used in the current paper.
References
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Acknowledgments
This study was supported by grant R40 MC 00319 (PI: Neumark-Sztainer) from the Maternal and Child Health Bureau (Title V, Social Security Act), Health Resources and Services Administration, Department of Health and Human Services. The first author was supported by the Adolescent Health Protection Program (School of Nursing, University of Minnesota) grant number T01-DP000112 (PI: Bearinger) from the Centers for Disease Control and Prevention (CDC). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the funding agencies.
