Strategies for maintaining a positive body image in the face of stigma

Introduction

While living with obesity can directly impact physical health and put the individual at risk of several chronic conditions (including diabetes, coronary heart disease and more) it can also affect mental health, where individuals may experience stigma, a negative body image and depressive symptoms. However, not all people living with obesity have a negative body image; some people who live with obesity maintain a positive body image and do not appear to be as affected by the negative experience of stigma. Less is known about how this group maintain their positive body image in the face of stigma. This paper explores this question using interviews with men and women who experience both obesity and a positive body image.

The rates of obesity and overweight are estimated to be at 2.5 billion worldwide and rising (WHO, 2024). Mirroring this is the rise in the experience of weight-based stigma (Myers and Rosen, 1999; Puhl et al., 2007, Puhl and Heuer, 2009; Westbury et al., 2023). This is concerning due to the consistent evidence base detailing the relationship between experiencing weight stigma and poorer health outcomes (for a review see Papadopoulos and Brennan, 2015). Mounting evidence suggests that this effect is partly driven by individuals internalising the stigma (Puhl et al., 2007). Internalised stigma comprises the following key features: ‘i) awareness of negative stereotypes about one’s social identity; ii) agreement with these stereotypes; iii) application of these stereotypes to oneself; and iv) self-devaluation due to one’s social identity’ (Corrigan et al., 2006). Internalised weight stigma specifically is associated with increased depression, anxiety and psychological distress as demonstrated in a systematic review and meta-analysis of 30 studies (Alimoradi et al., 2020). The consequences of stigma also impact physical health and weight management.

This association is accounted for in the Cyclic Obesity/Weight-Based Stigma model (COBWEBS), in which weight stigma is seen as a stressor or catalyst for stress (increased cortisol), leading to increased risk behaviours (eating behaviour) and, ultimately, weight gain (Tomiyama, 2014). Given that internalised weight bias mediates the effects of experienced weight stigma on stress, it is important to understand how some individuals can be more resilient to experiences of stigma and avoid internalising them. The experiences and perceptions of weight stigma for those who hold a positive body image may provide important clues (Schwartz and Brownell, 2004).

Research exploring the coping mechanisms used by those with obesity experiencing weight stigma highlights a range of strategies (Cash et al., 2005; Gerend et al., 2021; Myers and Rosen, 1999; Puhl and Brownell, 2003). Myers and Rosen’s (1999) early study of coded questionnaire descriptions indicated that ways of coping with obesity stigma included positive ‘self-talk’, countering stigmatising remarks, using faith, religion or prayer, eating and positive reframing. This was supported by a review which showed many ways of coping, including attempts to deal with and change the situation, and feelings of pride (Puhl and Brownell, 2003). Further work was facilitated by the development of a scale measuring coping with body image threat (the Body Image Coping Strategy Inventory; Cash et al., 2005), which identified three areas of coping: avoidance (of situations where stigma may be experienced), appearance fixing (covering or changing one’s appearance), and positive rational acceptance (acceptance and positive thoughts about one’s appearance). A more recent qualitative study (Gerend et al., 2021) found 12 coping strategies among individuals who experienced obesity stigma. The strategies supported those included in the Body Image Coping Strategy Inventory but also uncovered some new strategies, such as eating, distraction, meditation, social withdrawal, self-harm and rumination. Inspection of the range of coping strategies for this sort of stigma indicates that individuals can use varied strategies. Importantly, the helpfulness or effectiveness of these strategies also varies. Whereas some are perceived by participants as helpful or effective, other strategies were recognised as not useful (Gerend et al., 2021) or are known to contribute to poor mental health or physical risks (e.g. comfort eating, rumination, self-harm).

While the above studies discussed the coping strategies of people living with obesity, it is unclear what strategies are used by people with obesity who hold a positive body image (Schwartz and Brownell, 2004). A positive body image has been described as ‘accepting and holding favourable opinions towards and respecting the body’ (Tylka and Wood-Barcalow, 2015: 53) and people who hold a positive body image may have different experiences and/or use different coping strategies in the face of stigma. Knowledge of these coping strategies to maintain a positive stance, and which protect body image in the face of stigma, may be applicable and useful for others who struggle to hold a positive body image (Cwynar-Horta, 2016). In support of this, research has shown that exposure to those who are average-sized or body positive (those who have a and hold a positive body image) can have a positive effect for those living with obesity, leading to increases in emotional and physical wellbeing (Andrew et al., 2016; Cohen et al., 2019; Linardon et al., 2022) and reduced negative mental health outcomes (for a review Linardon et al., 2022). Intervention studies show that those who were either exposed to positive body images (Cohen et al., 2019; Stevens and Griffiths, 2020) or who listened to positive body-related songs (Coyne et al., 2021) reported increased satisfaction with body size and positive mood. This suggests that body positive images and environments may counter the negative effects of obesity stigma. Nevertheless, individuals with a positive body image are also likely exposed to images and environments that perpetuate weight stigma, and they may respond to such experiences in particular ways that help to maintain their positive body image.

Existing research exploring weight stigma coping strategies offers useful insights into how individuals handle such experiences, but to date there is no research focusing specifically on the strategies used by individuals with obesity who hold a positive body image. Knowledge of the strategies used by this group specifically would provide vital insights into methods to protect an individual’s sense of self and body image and provide guidance for the focus of interventions that aim to reduce the damaging impacts of weight stigma. It is also important to explore what types of stigmatising experiences, if any, individuals with a positive body image face. If this group turns out not to be exposed to weight stigma, then this could explain how they maintain a positive body image. However, if this group faces similar weight stigma experiences to those documented in past research, then their perceptions and reactions to these experiences may hold vital clues to how they maintain a positive body image. To this end, this study aimed to purposively recruit and interview individuals with obesity who self-identify as having a positive body image to explore qualitatively how they maintain this positive body image in stigmatising situations.

Methods

Participants

Sixteen participants were recruited from social media sites (e.g. Facebook, Twitter, LinkedIn, Instagram) and from the undergraduate cohort of a British University. Inclusion criteria ensured participants were UK residents over 18 years of age, with a BMI over 25 kg/m², who self-identified as having a positive body image. Specifically, we recruited those who self-identified as having a positive body image and used a score of >30 on the Body Appreciation Scale as an indicator that they did not hold a neutral or negative body image (Tylka and Wood-Barcalow, 2015). Participants (Table 1) included more women (n = 11; 69%) than men (n = 5; 31%), with an age range of 19–56 (M = 31.19, SD = 10.90). Just over half the sample (n = 9) identified as white. The final sample BMI ranged from 28 to 43 kg/m² (M = 31.88, SD = 3.85) and scores on the Body Appreciation Scale (BAS; (Tylka and Wood-Barcalow, 2015) ranged from 30 to 50 (M = 41.56, SD = 6.03). Participants were excluded if they reported diagnoses of eating disorders, other mental health disorders or identified as having a physical disability (due to possible experiences of other stigma).

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Table 1.

Participant demographic information.

Participant number	Sex	Ethnicity	Age	BAS score	BMI
1	F	White	39	49	35
2	F	White	29	50	28
3	F	White	20	47	35
4	F	White	43	45	31
5	F	White	56	41	43
6	F	White	19	40	34
7	M	White	33	32	30
8	F	Mixed	29	44	31
9	M	White & Black African	24	41	30
10	F	White	33	32	32
11	M	White & Black Caribbean	24	43	31
12	M	White & Black Caribbean	23	41	30
13	M	White	19	30	29
14	F	Pakistani	24	48	28
15	F	Spanish	36	43	35
16	F	Black African	48	39	28

BAS: Body Appreciation Scale.

Results

The main aim of the study was to explore how individuals with obesity who hold a positive body image experience stigmatising situations and how they maintain positive body attitudes in these situations. While the participants spoke of many experiences regarding their body size, the themes below (Table 2) were developed specifically from the comments that focused on, or reflected, strategies they used to maintain resilience against weight stigma. Theme 1 gives examples of the sort of negative interactions participants have experienced, including with friends and family, in the media or society in general. Theme 2 was developed from reports of how participants coped with and maintained a positive view of themselves using self-evaluative strategies that embraced or transcended their size (subtheme 2.1) or that ignored or dismissed stigmatising comments (subtheme 2.2). Theme 3 presents evidence of a more behavioural response where participants confronted or physically avoided the stigma. Finally, Theme 4 was developed from comments that highlight what participants found helpful.

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Table 2.

Overview of themes and subthemes.

Theme	Subtheme
Theme 1: Stigmatising experiences	1.1 Interactions with others 1.2 Society and Social Media
Theme 2: Cognitive self-evaluative strategies	2.1 Self-affirmation Strategies: ‘There’s so much more to me’ 2.2 Self-protection Strategies: ‘Don’t listen to other people’
Theme 3: Social behavioural strategies	3.1 Confronting Strategies: ‘How dare you say something like that’ 3.2 Avoiding Strategies: ‘I don’t want to even be near anyone that would be ashamed of me’
Theme 4: What helps? – the positive role of others	4.1 Positive support from others: ‘Having close friends who will stick by you through thick and thin’ 4.2 Positive Media: ‘Advertisements and such, they are a lot more realistic … they represent the real struggles of everyday life’

Discussion

This study aimed to understand the experiences of individuals with obesity who maintain a positive body image and how they maintain this positive view in the face of weight stigma. It was possible that people with a positive body image do not experience weight stigma and this may account for their positive attitude, but our results confirm that this group do indeed still experience weight stigma. This occurred both with their own personal interactions and interactions on social media, which left them feeling negative and feeling the need to conform to a thinner body shape. This links well to the evidence of weight stigma experienced by those who do not specifically hold a positive body image (Papadopoulos and Brennan, 2015) and so shows that people with a positive body image appear to experience the same type of weight stigma as others. Accordingly, the strategies used by those with a positive body image in response to these experiences may be crucial to understanding their resilience.

Our results show how people with a positive body image maintain their positive attitude in the face of a society where weight stigma is common. The self-evaluative cognitive strategies that our participants used included self-affirming strategies and self-protective strategies. The self-affirming strategies included an acceptance of their size and a shifting of their values and priorities, for example, to see that they are more than their ‘flaws’ or that there are more important aspects of life than body size. Self-affirmation is a means of bolstering the self by focusing on values, strengths or positive experiences in other domains (Steele, 1988). Self-affirmation is well-established as a way to preserve feelings of self-integrity, self-worth and wellbeing in the face of threats (e.g. feedback, health messages, stress; Cohen and Sherman, 2014; Howell, 2017). It can be conceptualised as a form of self-enhancement (Hepper et al., 2010) or a more adaptive form of self-protection that enables one to process a threat in a less defensive way (Hepper et al., 2022; Sherman and Hartson, 2011). Self-affirming strategies have previously been reported by interviewees as ways of coping with weight stigma (Alleva et al., 2023; Gerend et al., 2021) and divorce (Butkutė et al., 2023). Amongst other coping responses used by participants with obesity in prior literature, our self-evaluative cognitive strategies align with self-talk and acceptance (Myers and Rosen, 1999) and positive rational acceptance, where individuals coach themselves about their positive attributes (Cash et al., 2005; Tylka and Wood-Barcalow, 2015). Our evidence shows for the first time that people with a positive body image, in particular, make use of these strategies. Promisingly, there is evidence that self-affirmation may lead to weight loss, if desired (Logel and Cohen, 2012). This is also supported by prior research that has shown that increasing body diversity in the media relates to improved beliefs surrounding functionality satisfaction, in which the focus is instead on what a body is capable of, rather than what it looks like (Mulgrew and Tiggemann, 2018).

The more dismissive cognitive strategies that emerged in our study included not listening to what other people have to say, ignoring stigmatising messages, or criticising the source, whether it be a person or a media-based message. These all reflect defensive self-protection strategies, which are intended to deflect and protect self-worth from threats (Hepper et al., 2010). There was also evidence of participants using distraction techniques, which are also self-protective behaviours (Gerend et al., 2021; Myers and Rosen, 1999). These comments tended be phrased in a way that indicates a positive, optimistic attitude to weight. Along with the positive, self-affirming cognitive strategies, these self-protective strategies might serve to reduce aspects of internalised stigma (cf. Corrigan et al., 2006). That is, although participants reported awareness of negative stereotypes, self-affirmation may help to reduce agreement with them, defensive self-protection may help to reduce application of stereotypes to the self, and both may help to reduce resulting self-devaluation.

However, while self-protection strategies may function in protecting self-worth, they have the disadvantage of not allowing the individual to learn from the situation (Cohen and Sherman, 2014; Sherman and Cohen, 2006). In line with these cognitive signs of self-protection was the Social Behavioural theme in which participants described actively avoiding stigmatising situations or people. This is supported by previous research; avoidance has been widely reported as a common strategy amongst other studies exploring the stigmatising experiences of those with obesity (Cash et al., 2005; Gerend et al., 2021).

Another, more approach-oriented type of self-protection is confronting; our participants also spoke of confronting the source of the stigma. This usually involved speaking out to the friend or family member. This behaviour requires some confidence and aligns well with Myers and Rosen’s (1999) coping response inventory (being nice to others, educating others, and telling them off). However, this is not one of the main coping strategies reported by Cash et al. (2005), Gerend et al. (2021), or as a prevention strategy aimed at improving body image (Tylka and Wood-Barcalow, 2015). The participants in our study all reported having a positive body image and it is possible that these individuals felt empowered to confront those who make stigmatising comments or may have not internalised the stigma and felt confident to confront the source of the stigma. Interventions to help people cope with weight stigma may therefore benefit from a focus on self-efficacy to encourage or facilitate effective confrontation.

The final theme was developed from comments that related to what participants reported helped them in stigmatising situations (as opposed to how they themselves dealt with them). This theme related to external support, as comments all referred to family and friends’ unconditional support and acceptance as helpful. Participants also referred to the positive effects of the media where it was comforting to see large sized models used in advertising (Stevens and Griffiths, 2020). Self-enhancement was evident wherein participants felt good about themselves after these interactions (Sherman and Hartson, 2011). Seeking social support is one of the 12 coping strategies listed in prior research (Gerend et al., 2021; Myers and Rosen, 1999), so while our participants did not speak of seeking support, their comments still support the positive role that social support may play in dealing with weight stigma. Research shows that it is often the perception of available social support, more so than actual receipt of enacted support, that is most related to successful coping and wellbeing (e.g. Siedlecki et al., 2014). Indeed, sometimes receiving visible support can be harmful by implying weakness or indebtedness (Bolger et al., 2000). Hence, our participants may not have felt the need to seek social support actively even though they acknowledged finding it helpful, but further research is needed to confirm this. This suggests that interventions to help with weight stigma may focus on perceived availability of social support (rather than ‘actual’ enacted social support).

It is noteworthy that despite the prominence of supportive close relationships in participants’ accounts of what is helpful, some of their strategies for managing weight stigma involved confronting or avoiding close others—strategies that entail risk of damaging the very relationships that could be providing support. Perhaps individuals with a positive body image engage in ‘social pruning’ to focus on the relationships that already provide them with the support they need and move away from potentially toxic relationships. Future research could explore whether this selective narrowing of social networks serves emotion regulation, similar to that seen most strongly in older adulthood (O’Brien and Hess, 2020). However, several participants expressed regret that they were unable to have positive relationships with family members. Moreover, more constructive confrontation interactions could have the potential to instil change in the other person, cultivating an improved social support network and ultimately contributing to improved societal attitudes. Future research could explore the conversations and communication styles in such interactions to understand what creates a positive outcome for both parties.

While our results have supported some previous research, in comparison with the weight stigma coping strategies identified in the literature (Cash et al., 2005; Gerend et al., 2021; Myers and Rosen, 1999) we did not find that participants reported eating, meditation, self-harm, rumination, weight management, impression management (Gerend et al., 2021), use of faith or religion (Myers and Rosen, 1999) or appearance fixing (Cash et al., 2005) as strategies. The above three studies all recruited people with obesity; however, none of them reported having a positive body image. Many of these strategies suggest a negative view of their size and shape (eating, self-harm, and rumination) and imply attempts at conforming to the thin ideal (weight management, impression management and appearance fixing), which may account for their omission from our data given that our participants had embraced their size and shape. The evidence of the use of meditation to reduce the stress associated with the stigma (Gerend et al., 2021) and religion to consolidate (Myers and Rosen, 1999) as strategies may relate the internalisation of the negative stereotypes in these samples, while our participants, having a positive body image, may not have internalised such views. Once again, further research is needed to confirm this. Our results show enhancement, protective and affirmative strategies were perceived as helpful for our participants and this holds promise for interventions to increase self-compassion and self-affirmation (Logel and Cohen, 2012).

Taken collectively, our findings add to the notion that a positive body image may counter some of the negative effects of obesity stigma. One explanation for this could be that it protects against the internalisation of weight stigma experiences. Given that body dissatisfaction and internalisation of the thin-ideal are key aspects of internalised weight stigma, it is plausible that a positive body image could serve as a protective factor. Our findings identify cognitive and behavioural strategies that might serve as mechanisms for this protection.

Our study is not without limitations. Inherent in all qualitative studies is the limitation that the results and conclusions are reliant on the verbal fluency of our participants and these reports are the perceptions of these individuals. However, we were interested in these very perceptions and so a qualitative methodology was the most appropriate method to allow an in-depth exploration of how people feel and react in weight stigma situations. We took a reflexive approach in the data collection and analysis to ensure we were aware of our biases and the coding and theme development took place within the research team. In addition, although data saturation was achieved, the results of our study may be limited by our sampling strategy, whereby those not using social media or who were not associated with the university may have been different in some way and hold different views. We attempted to avoid this by recruiting in more than one location. However, we were not able to look at differences between individuals depending on where and how they were recruited. Another limitation lies with the definition and range of positive body image in our sample. We recruited those who self-identified as having a positive body image, and while we did use the BAS to ensure that participants did not hold a neutral or negative body image, some were more positive than others. Finally, our sample varied in cultural background and age, but older adults and men were under-represented. Our study did not aim to assess the effects of cultural beliefs as, although these influence body image perceptions (Schwartz and Brownell, 2004), we were interested in experiences and reactions relating to stigma situations. Future research should aim to recruit older participants and more men for a fuller understanding of the experiences and strategies used by different groups.