obesidad y bullying

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nature publishing group

Weight Bias Supplement

The Impact of Weight-related Victimization on Peer Relationships: The Female Adolescent Perspective Lucy J. Griffiths1 and Angie S. Page2 Objective: Obesity is associated with undesirable psychological and social consequences. This qualitative study examined the relationship between obesity and victimization, and the impact this has on peer relationships.

Methods and Procedures: Five obese female adolescents participated in multiple, semi-structured, in-depth interviews. Interview transcriptions were analyzed using Interpretative Phenomenological Analysis (IPA).

Results: Weight-related victimization experiences were common and their impact on peer relationships was complex.

Low self-confidence, isolation, and peer anxiety were all identified as resulting from victimization and were all barriers to developing peer relationships. Participants sought protection from victimization by seeking the “ideal” nonjudgmental empathetic best friend(s) and supportive family members to shield them from negative experiences.

However there was also evidence that, while they were guarded with their own feelings, the experience of victimization increased empathy in these obese female adolescents.

Discussion: Social and psychological consequences of obesity in female adolescents are widespread, suggesting the importance of listening to those affected. Peer relationships have the opportunity to both amplify and reduce the psychological impact of living with obesity and victimization. Greater understanding of the social networks of obese adolescents and their impact on well-being is needed, as well as methods to reduce negative experiences through childhood obesity treatment and school-based prevention programs.

As the prevalence of childhood obesity increases in the developed world, so too does stigmatization of the obese body (1).

A growing literature reports predominantly negative attitudes toward obese children, with them being rated by peers as being less popular, friendly, intelligent and attractive, and more mean, lazy, argumentative, sad and dirty than nonobese peers (2–7).

Obese young people often report impaired social relationships. Compared to normal-weight peers, obese adolescents have been found to have fewer friends (8,9), whereas obesity can also negatively affect adolescent dating status (10). Obese children also report that changing their weight status, i.e., ­losing weight, would increase their number of friends (11).

Stigmatization is often suggested to go beyond social marginalization or isolation, with young overweight people encountering bullying-victimization due to their weight status (10,12–16). Bullying-victimization refers to an individual being repeatedly exposed to negative actions of others’ with the intention to hurt (17) and can be overt (physical (e.g., ­hitting), verbal (e.g., name calling)), or relational (e.g., social exclusion) (18,19). Determining the prevalence of weight-related victimization is challenging (20), although evidence suggests

that its occurrence is widespread and greater among more overweight children (10,14,16,21). Obese young people report being the victims of all forms of bullying (10,16). However, obese preadolescent boys (16), and male and female adolescents (21), are also reported to be the perpetrators of bullying.

This has been suggested to be a result of their physical dominance among peers and/or due to confrontation in the face of victimization (16).

Being the target of victimization has been found to be associated with psychosocial maladjustment, such as increased anxiety, body dissatisfaction, depressive feelings, loneliness and lowered self-esteem (20,22). As such, it is important to gain further understanding of these experiences and the emotional and social consequences. Qualitative research, in particular, yields important insight into socially complex experiences of obesity and victimization. Qualitative literature to date has confirmed the widespread occurrence of bullying, commonality of school-based experiences and a range of emotional responses including heightened self-awareness of physical status and high self-consciousness (11,23–25).

This study aims to extend our understanding of weight­relation victimization experiences of obese young people

1 MRC Centre of Epidemiology for Child Health, UCL Institute of Child Health, London, UK; 2Department of Exercise, Nutrition & Health Sciences, University of Bristol, Bristol, UK. Correspondence: Lucy J. Griffiths (l.griffiths@ich.ucl.ac.uk)

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and how, in particular, this impacts on peer relationships.

Peer relationships may have the potential to both amplify and reduce the psychological consequences of victimization.

Consequently, increased understanding of how victimization impacts on peer relationships can assist in the development of strategies to reduce victimization and foster more positive relationships and social networks between obese adolescents and their friends and family.

Methods and Procedures Sampling and participants

Sampling in qualitative research involves the purposeful selection of individuals who can provide rich description of the phenomenon being studied (26). This study used criterion sampling to purposefully identify information-rich cases ­worthy of in-depth study (27). This strategy was used to recruit obese young people and their parents from the Care of Children with Obesity Clinic, Royal Hospital for Children, Bristol, UK. Patients were identified who were (i) female, (ii) adolescents (young people aged 12–18 years), (iii) above the 95th percentile of British age- and gender-specific growth reference data, thereby defining them as obese (28), and (iv) had English as a first language, which was necessary for the in-depth interviewing process. Patients were excluded who had genetic susceptibilities for obesity, e.g., Prader–Willi syndrome or learning difficulties. Young people who had reached adolescence were recruited to allow greater depth of experiences and perceptions to be explored, uninhibited by developmental cognitive issues. This age group also presented fewer problems in their willingness to be interviewed without the presence of ­guardians, whose presence may have inhibited discussion of sensitive issues.

Based on these criteria, 12 participants were invited to take part in our study, of which, five female adolescents provided verbal and written consent enabling involvement. While no rules define an appropriate sample size for qualitative work (26), the sample here was restricted to females from a limited age group to maximize the potential for rich data generation from a small, but particularly vulnerable, clinical group. Details of the five participants are provided in Table 1.

Data collection

Given the choice of a university or home venue, all participants asked to be interviewed within their own home. Multiple (two or three) interviews were conducted by the author (L.J.G.) to develop good rapport, defined as “positive feelings that develop between the interviewer and the subject” (29); this is an essential component of the interviewing process to enhance honesty and disclosure from the participant. This in-depth approach is crucial when seeking to obtain such personal information from vulnerable individuals. Interviews were semi-structured in nature and covered a range of themes including global and physical self-perceptions, peer relationships, victimization experiences, and weight management behaviors. This article just focuses on the information obtained relating to the adolescents’ peer relationships and victimization experiences.

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Interviews were audio-recorded and ranged in duration from 45–120 min, with follow-up sessions taking place one week later; this time frame enabled the interviewer to reflect on the proceedings and information obtained and to transcribe the interviews concurrently. Ethical approval for this study was obtained from the United Bristol Healthcare Trust.

Analysis

The principle technique used for this study is adopted from phenomenology and is called interpretative phenomenological analysis (IPA) (30,31), described as an appropriate method for analyzing qualitative information derived from semi-­structured interviews (31). IPA aims to explore meaningful experiences of individuals and is, therefore, concerned with trying to understand an individual’s personal world through their perceptions or accounts of states or experiences, as opposed to attempting to produce an objective record of experiences; this is enabled through interpretative, intensive engagement with texts and transcripts (32).

IPA involves three stages, which were adopted in this study: (i) interview audio-recordings were personally transcribed verbatim, providing familiarity with the narratives, while ­initial thoughts and ideas were jotted down in a research journal; (ii) transcripts were read repeatedly and marginal remarks were made, detailing ideas, reactions to quotations, initial thoughts and observations; and, (iii) through analytical reading of the information, conceptual themes were identified and labeled to characterize the essential quality of the text, using IPA. Textual statements, which captured perceptions, thoughts and feelings about experiences or states were, therefore, specifically identified.

The IPA technique used within this study also acknowledges the subjective features implicit to in-depth data analysis, with findings the product of the researcher’s interpretation of, and engagement with, participants’ accounts. Stages of the analysis process and emergent themes were continuously discussed with the fellow author (A.S.P.) to reduce subjectivity. Furthermore, to enhance rigor of the findings, this study adopted a mixture of procedures suggested by Creswell (33) and Wolcott (34), including (i) prolonged engagement, (ii) “talk little, listen a lot”, (iii) obtain rich, thick description, (iv) record accurately, and (v) report fully. Additionally, a research journal was kept by the author (L.J.G.) as a documentary tool immediately after each interview to reflect on the process and atmosphere; this is an important process of IPA to enhance the researcher’s ability to “walk a mile in the other person’s shoes” and therefore to enhance understanding of the individual’s point to view.

Results

First, victimization experiences that emerged from the data, coping strategies and negative psychological consequences will be described, followed by a description of the themes that emerged from the participants’ interviews regarding the impact of these experiences on peer relationships: importance of a best friend, guarded trust, isolation, family as shield, peer anxiety, low self-confidence as a barrier, and supporting others.

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Table 1 Participant characteristics Pseudonym

Age

BMI (kg/m2)

Obesity history

Ann

17

43.3

Weight concerns since early childhood

2

Sam

15

38

Childhood un-plagued with weight concerns; weight gain in recent years

2

Beth

12

36

Weight had steadily increased since childhood

1

Kim

13

34

Rapid weight gain in the past five years

0.5

Jane

17

46.7

Weight had steadily increased from childhood, attributed largely to early development of arthritis

2

The participants’ names were changed to protect their identity.

Verbatim quotes are used throughout.

Victimization experiences

All of the participants in this study reported being the victims of bullying but the nature of the attacks varied and, although not exclusively the case, most of these experiences were described as being the result of weight stigmatization. Sam reported direct physical bullying.

Sam: I got threatened with a switchblade...I had a flying kick done at my leg and I had a bruise eight inches long by two inches wide on my leg—done by a boy, he was jumping off one of the logs that they used for chairs in the playground.

All participants reported instances of verbal and relational bullying.

Sam: It’s not nice to be called like, “bitch,” “fat cow,” “your mother’s a whore,” I mean, stupid stuff like that… you want to squash them like cockroaches, which would be very satisfying, but not possible.

Jane: I couldn’t hear what they were saying but I knew they were saying stuff as I was going past, whispering stuff. I suppose when I first went to [school name] it was a bit of a problem…I didn’t know anyone. So, at the beginning, it was a bit...but I just ignored it, I just went to the teacher. It was like name-calling. Nobody ever hit me or anything like that, but I think that was partly because they knew I’d get them back harder, ’cause I am a lot bigger than them.

Ann: There was this girl who was about my size and she would go around going “you’re a fat pig. Joke!”

You know that sort of joke, where they’re not actually ­joking. They’re just being as hurtful.

Kim: I used to get bullied for like two years. They used to just like pick and choose when they wanted to be friends, whisper about me all the time and everything.

I don’t know what they were actually saying…just like calling me “fat” and everything. If they say it now they would get a punch.

Attendance at obesity clinic—years

For Beth, Ann and Kim, victimization was a problem of the past. In contrast, Sam and Jane were still experiencing victimization at the time of interview.

The majority of negative experiences described took place within school, with peers being the perpetrators. One teenager felt that it was more common in state than private schools and victimization was more commonly reported in primary (also known as junior) (4/5–10/11 years) compared to secondary school (11/12–16 years).

Beth: I used to like get picked on in school but it all stopped when I went in year six [secondary school].

Ann: When I was at junior school I was teased horrifically by all sorts of people, really badly. I spent most of my childhood, in school, in tears behind the sheds or something. Those who didn’t avoid me would tease me until I just couldn’t hack it, and it lasted for such a long time.

Within school, heightened experiences during physical education classes were also prevalent. These were usually described as being triggered by physical difficulties or capabilities and the importance that peers placed on an “attractive” body.

Sam: I’ve put on the weight and I still want to do it [participate in physical education classes] but it’s the glances, it’s the sniggers, it’s the laughs…stupid things that people were saying, “look at her running along, she can barely keep-up.”

The participants reported a range of coping strategies. Sam responded to victimization with anger and verbal blasphemy, and she had in the past physically retaliated: Sam: I was so vicious in junior school compared to what I am now…there was this one bloke in particular, I punched two of his front teeth out and slammed another girls’ head against the window sill. I knocked unconscious a boy three years older than me.

Kim’s approach was to join a friendship group which was tough and rebellious. She had befriended peers who had previously bullied her. She suggested that victimization was less of a problem for her now as she hung around with “hard people” and therefore peers were “scared” of her. Beth also reported

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physical retaliation for self-protection and had attended Judo classes. Additional strategies included informing teachers and parents but, for Jane, avoidance and having physical support from a companion were most important: Jane: I don’t like having to walk into places where I don’t know anyone or walking past a group of people; I don’t like walking past because of things they might say and they are less likely to say if I’ve got Diane ­[sister] with me.

Victimization had a number of negative psychological consequences for these participants. The most striking attribute was low self-confidence and related body dissatisfaction.

Kim and Sam felt more confident with peers who knew them before they became overweight, from whom they received less stigmatization.

Jane: Confidence affects me. Um, I suppose being called names, or not fitting in, or not being able to do things I think.

For Ann, this also resulted in lack of parental support: Ann: Mum used to say, “got to lose weight as nobody’s ever going to love you,” stuff like that. Very, very, bad body image developed from a very young age basically and inspired self-disgust to a degree.

The participants also reported feeling down or depressed: Sam: I was really miserable…I was depressed because of bullying.

However, the teenage stories also reflected a mental struggle to try not to let victimization affect their sense of self or mood. The older girls (Jane and Ann) felt they had learnt to deal with it.

Jane: There’ll be some times when I’m feeling like perhaps a bit down or something for any reason, and then someone will say something and it’ll just get to me more than it would normally…I don’t like it, but you can’t stop it completely. It’s either let it affect you all the time or get on with it. So, I just try to get on with it otherwise it brings me down.

Ann: I’m not as affected by mocking and stuff like that. It’s just not an issue for me. When I was little I got mocked so much I know more fat jokes than anybody else going. I’m better at it than they are. I spent just such a long time being bothered by it and I got so low on so many occasions. Now it’s just like, “you have a problem with me, that’s your problem.” Ultimately, mocking doesn’t get them anywhere, not any more.

Beth told a different story. No longer a victim of bullying, she displayed greater confidence than the other participants and S42

showed a keen interest in performance and drama at school.

Nevertheless, ambiguity was reflected in her stories and her desire to perform by her tendency to play the jolly fool in front of peers, perhaps to look more confident: Beth: I’d say I’m a bit funny, don’t know why. Everyone just laughs at me and thinks I’m a weirdo…sometimes you act as you want to be popular. I’d say I’m a bit naughty. I’d say talkative as well, I can be. Other times I am quiet…I wouldn’t say I’m always myself, not always me.

Impact of victimization on peer relationships

This section will describe seven themes that emerged from the interviews which relate to the impact that victimization had on the participants’ peer relationships.

Importance of a best friend. All girls expressed the desire for the

ideal “best” friend(s) who was supportive, nonjudgmental and empathetic. Having a good friend had a number of advantages.

First, they represented someone to talk to about everyday feelings and concerns, therefore providing moral support.

Ann: It’s useful because I can imagine slowly going completely mental if I couldn’t, you know, feel open enough to talk about stuff with people and get it out into the open and not feel restricted by all the stuff that’s weighing me down.

Beth: I like having close friends because you can have your family, but friends are also always there to help you.

Being able to talk to friends also offered the opportunity for others to understand problems and to off-load feelings weighing them down.

Sam: You both respect each other’s feelings enough to understand problems, or differences, or the same sorts of things between each other so...it’s just a feeling both people have usually…We talk and we understand each other and we help each other get through like distressing times…Because she knows a lot about me and I know a lot about her. We respect each others feelings enough to understand what the other person is feeling at the time.

Above all, a good friend provided company, someone to “hang around with them all the time” (Kim).

Guarded trust. Despite the importance of a best friend, a few of the participants displayed guarded trust, or the inability to talk about very personal issues related to their weight, and reluctance to accept/believe compliments received from friends:

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things, like if something has gone wrong or...but not like how I feel, like if someone says something to me I won’t say anything about it, or whatever. I’m like that with most people…I don’t tell her. I’ve never told anybody how I feel about anything. It’s not just that I won’t tell her, I won’t tell anybody.

Ann: I know my friends aren’t thinking how I feel they are thinking…they don’t see me like that [fat], they just see me as a person but, you know, logic and feeling are very different.

Isolation. Feelings of (peer) isolation were expressed. These

resulted from feelings that friends could not fully understand the impact that obesity had on their everyday life, feelings of loneliness, and awareness of physical limitations.

Ann: Separated from them [friends] all the time because you’ve got something that they couldn’t understand… there is no way they possibly could understand. Because it does control so much of your life, and have an affect on so much of your life, they can’t understand just how so encompassing it is and just how much it affects.

Sam: I don’t have anyone else to hang around with Jane: I can’t join in or I don’t want to join in because I know that I can’t do it...or perhaps I won’t go down the high street because I know I’ll be left behind.

Family as shield. Like close friends, family members pro-

vided support and protection from anxiety-provoking people and situations. Similarly, being at home was perceived to be a safe environment. For example, Kim felt most confident at home, away from the threat of victimization, and feelings of self-­consciousness related to her body. Jane also relied on her younger sister, Diane, or her mother, to accompany her whenever possible when out and about.

Jane: Don’t like being around people I don’t know, I suppose. I don’t like having to walk into places where I don’t know anyone or walking past a group of people.

I don’t like walking past ’cause of things they might say and they are less likely to say when I’ve got Diane with me.

Peer anxiety. Victimization was related to anxiety among

groups. No longer a victim of bullying, Ann’s relationships with peers outside of her friendship group were described as amicable although they were not people she would socialize with. Similarly, Beth, no longer felt anxious as she felt more accepted in secondary school. Kim, clearly felt safer when she was with family and her tough group of friends. However, Sam and Jane, who reported still being bullied, displayed a high degree of anxiousness and discomfort in being around people that were less well known.

However, these interviews also revealed anxiety even among close friends that was related, not to victimization per se, but body dissatisfaction as a result of their weight and/or size. All of the participants in this study suggested that lack of social acceptance contributed to dissatisfaction with their physical status, and that dissatisfaction with their physical self made it harder to be in social situations.

Sam: I want more sleepovers; unless I’ve been friends with them for a while it’s difficult because of my weight.

Ann: …this is getting into my psyche a bit, but selfdisgust. I’m so disgusted...I’ve grown up being so disgusted by myself physically that I hate to think of somebody I like having to be near that [her body]. As I said this is getting really hyper-complicated psychologically I suppose, probably yeah, but I wouldn’t inflict me on somebody else if I could help it, especially somebody I care about.

Low self-confidence as a barrier. Low self-confidence was a

characteristic of all of these participants, with the exception of Beth, to some degree. This negative self-perception was reported to be a barrier to approaching new people and developing friendships. This was especially evident in Jane, and made her particularly value friendships when they were available (e.g., at college).

Jane: It [having a friend] makes me feel more confident in myself. I feel that if I have a friend then it makes me feel more confident to make more new friends.

Sam: My abilities to make friends with people, because I find it very difficult, but I think that is just because I don’t have much confidence because of my weight.

Both Ann and Beth suggested that they were not as confident as friends perceived them to be and both reported “playing a role,” or manipulating their self-presentation, to increase acceptance.

Ann: Everybody wants to make a good first impression.

I’m very nervous about a lot of things ’cause I’m lacking in self confidence and ever since I was very little I’ve made up for that by going over-self confident, or appearing to be…So, you’ve got to appear more than perfect, more than acceptable, to make up for what you lacking otherwise.

Supporting others (friends and family). A common theme across all participants was the great emphasis that they placed on providing support to close friends and family members.

Beth: I can always be there for my friends if they need someone.

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However, this was strongest in those who had experienced family difficulties (Ann and Kim), perhaps suggesting their greater reliance on these friends.

Ann: …It gives me a reason to be around, you know.

Making other people happy tends to make me happy… having somebody to look after, feel responsible for, make happy, especially making happy- like I said, I get really happy by making other people laugh, smile, be happy, erm, feel special. ’Cause I think everybody needs to feel special, and I get a huge buzz out of knowing I’m achieving that for somebody, making them feel like they’re the most important person in the world.

Discussion

While a growing number of quantitative studies have investigated psychosocial consequences of childhood obesity (20), few have focused on the social impact of victimization. The qualitative nature of this research sought to obtain the points of view of female adolescents living with obesity, to explore weight-related victimization and the impact of this on their peer networks and relationships.

All of the participants in this study had or were currently experiencing victimization which, in the majority of cases, was weight-related. The participants in this study were not selected on the basis of victimization experience although, as indicated earlier, this was a clinical sample of obese young people and victimization experiences are more prevalent in children with higher levels of obesity (14). Physical, verbal and relational forms of bullying were all independently reported, with the latter forms being more common. This suggests that school antibullying policies, like the UK “Safe to Learn” policy (35), need to emphasize the commonality of appearance-related bullying.

Furthermore, they should provide clear examples of verbal and relational bullying alongside more established physical instances, to make clear to students and staff that these are more prevalent in relation to weight and can easily be “hidden” within the school environment. Strategies should be put in place to encourage students to discuss instances of verbal and relational attacks and have mechanisms set-up to allow this to be recorded and acted upon within the school setting.

In response to victimization, coping strategies included avoidance and confrontation—strategies also identified in a review by Puhl and Brownell (36). We have previously reported that preadolescent boys, but not girls, use their size to bully as well as be a victim of bullying (16). Within this study of adolescent females, participants described using their size to “threaten” or deter individuals from victimizing them. It is expressed as a last resort and may be a coping strategy that develops with age and size in adolescent females when other strategies don’t appear to work; overt bully perpetrating in this population has also been identified by Janssen et al. (21). Although this strategy may appear pragmatic to these females, it should be discouraged and bullying strategies should enhance the development of nonviolent coping strategies.

The findings emphasize the negative influences of stigmatization on emotional well-being, including low self-confidence, S44

body dissatisfaction and depressed feelings, with some, but not necessarily all, of these young people internalizing attributions of social worthlessness. However, the temporal impact of victimization is complex; this can fade with time for some victims, while it may have a more acute long-term negative influence on other victims even though the bullying experience was some time in the past. This detrimental impact can track through to adulthood, as research has shown that adolescents bullied repeatedly through adolescence have lower self-esteem and more depressive symptoms as adults (37). Consequently, it is imperative that these adverse consequences on mental wellbeing are addressed early.

The second goal of this study was to examine the impact of weight-related victimization on peer relationships. Although we have presented individual themes in the findings, these could be grouped into three higher-order constructs: (i) barriers to peer relationships, (ii) importance of support, and (iii) relationships in general. These groupings are developmental and require confirmation in further research, but we feel they allow an enhanced interpretation of these findings. Our findings show that low selfconfidence, isolation and peer anxiety are all direct consequences of bullying experiences and they all affect ability to develop and maintain peer relationships. These have therefore been categorized in (i) barriers to peer relationships. Consequently, to improve social networks, these barriers need to be acknowledged and addressed through social and cognitive strategies to promote adaptive self-evaluations (38). This needs to be combined with a supportive environment—a factor often described by the participants in this study and the second higher-order construct we identified. The importance of having a best friend was a common theme across participants, while the occurrence of using family members to shield them from victimization experiences was also emphasized. These two themes provide clear evidence that having a support network either from good friends or family helps to alleviate the impact of bullying. Existing research suggests that one mechanism by which this is achieved is through the development of interpersonal skills enabling victims to deal with bullies (39). Furthermore, support networks can also enable the development of other friendships and relationships, through increased confidence and self-belief of worthiness. Finally, the “friendships in general” construct incorporates the themes “supporting others” and “guarded trust.” We have shown that lack of enhanced support (see above) and other experiences impact on relationships in both a positive and negative way; their own experiences appear to enhance empathy for others and all participants suggested the importance of supporting or helping others.

However, their guarded approach to these relationships suggests their vulnerability to weight-based stigmatization and may reflect concern that closer social interaction leaves them open to greater psychological damage from negative experiences.

While the credibility of qualitative research is often questioned due to the influential role of the researcher on the information obtained and their interpretation of the participants’ stories, the in-depth interviewing techniques and IPA procedures used within this study provide clear perspectives of the participants, thus allowing their “voice” to be heard. The VOLUME 16 SUPPLEMENT 2 | NOVEMBER 2008 | www.obesityjournal.org

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participants were open and honest and described very personal self-perceptions and experiences. Exemplifying quotations are presented to the reader to highlight the salience and depth of these findings. Further qualitative work should be conducted with male obese adolescents and obese young people from racially, ethnically, and economically diverse backgrounds.

This may enhance the understanding of the role of gender and cultural values on social acceptance and self-evaluations.

Conducting interviews with peers and teachers would also provide alternative perspectives on the social relationships of obese young people. Using longitudinal data, both qualitative and quantitative, would also determine the short vs. long-term effects of victimization and the development of peer relationships over time. Investigation of key transition periods representing a shift in social networks, such as the transition from primary to secondary school, may be particularly useful.

Methods to reduce negative peer experiences of childhood obesity are a crucial target for intervention. Psychological consequences of obesity receive less attention in the majority of interventions than physical consequences. Modules to improve social relationships and peer interactions, such as cognitive and behavioral strategies to improve social skills and competence, along with more standard self-esteem development would be an important contribution to obesity treatment programs in this age group. School-based antibullying policies should also focus on the promotion of weight tolerance and reducing the stigma of obesity as well as working with victims of bullying on appropriate nonviolent coping strategies. This study has provided unique data to inform these interventions from the perspective of the female adolescent living with obesity; this voice is rarely heard.

Acknowledgments We are extremely grateful to the young people involved in this study, who spoke so candidly about their experiences without which this research would not have been possible. Our thanks also to Julian Shield, Elizabeth Crowne and Matthew Sabin at the Bristol Royal Hospital for Children, and to Emmanuel Stamatakis, now based at University College London.

Disclosure The authors declared no conflict of interest. © 2008 The Obesity Society

References 1. Latner JD, Stunkard AJ. Getting worse: The stigmatization of obese children.

Obes Res 2003;11:452–456.

2. Staffieri JR. A study of social stereotype of body image in children. J Pers Soc Psychol 1967;7:101–104.

3. Lerner RM, Korn SJ. The development of body-build sterotypes in males.

Child Dev 1972;43:908–920.

4. Harris B, Smith SD. The relationship of age, sex, ethnicity and weight to stereotypes of obesity and self-perception. Int J Obes 1983;7:361–367.

5. Hill AJ, Silver EK. Fat, friendless and unhealthy: 9-year old children’s perception of body shape stereotypes. Int J Obes 1995;19:423–430.

6. Wardle J, Volz C, Golding C. Social variation in attitudes to obesity in children. Int J Obes 1995;19:562–569.

7. Tiggemann M, Wilson-Barrett E. Children’s figure ratings: Relationship to self-esteem and negative stereotyping. Int J Eat Disord 1998;23:83–88.

8. Strauss RS, Pollack HA. Social Marginalization of Overweight Children.

Arch Pediatr Adolesc Med 2003;157:746–752.

9. Falkner NH, Neumark-Sztainer D, Story M, Jeffery RW, Beuhring T, Resnick MD. Social, educational, and psychological correlates of weight status in adolescents. Obes Res 2001;9:32–42.

10. Pearce MJ, Boergers J, Prinstein MJ. Adolescent obesity, overt and relational peer victimization, and romantic relationships. Obes Res 2002;10:386–393.

11. Pierce JW, Wardle J. Cause and effect beliefs and self-esteem of overweight children. J Child Psychol Psychiatry 1997;38:645–650.

12. Hill AJ, Murphy JA. The psycho-social consequences of fat-teasing in young adolescent children. Int J Obes 2000;24(Suppl 1):S161.

13. Cattarin JA, Thompson JK. A three-year longitudinal study of body image, eating disturbance, and general psychological functioning in adolescent females. Eating Disord J Treat Prev 1994;2:114–125.

14. Neumark-Sztainer D, Falkner NH, Story M, Perry CL, Hannan PJ, Mulert S. Weight-teasing among adolescents: correlations with weight status and disordered eating behaviors. Int J Obes 2002;26:123–131.

15. Eisenberg ME, Neumark-Sztainer D, Story M. Associations of weight-based teasing and emotional well-being among adolescents. Arch Pediatr Adolesc Med 2003;157:733–738.

16. Griffiths LJ, Wolke D, Page AS, Horwood JP, ALSPAC Study Team. Obesity and bullying: different effects for boys and girls. Arch Dis Child 2006;91: 121–125.

17. Olweus D. Sweden. In: Smith PK et al. (eds). The Nature of School Bullying: A Cross-national Perspective. Routledge: London, UK, 1999, pp 7–27.

18. Bjokquist K. Sex differences in physical, verbal and indirect aggression: a review of recent research. Sex Roles 1994;30:177–188.

19. Crick NR, Grotpeter JK. Relational aggression, gender, and socialpsychological adjustment. Child Dev 1995;66:710–722.

20. Puhl RM, Latner JD. Stigma, obesity, and the health of the nation’s children.

Psychol Bull 2007;133:557–580.

21. Janssen I, Craig WM, Boyce WF, Pickett W. Associations between overweight and obesity with bullying behaviors in school-aged children.

Pediatrics 2004;113:1187–1194.

22. Hawker DSJ, Boulton MJ. Twenty years’ research on peer victimization and psychosocial maladjustment: A meta-analytic review of cross-sectional studies. J Child Psychol Psychiatry 2000;41:441–455.

23. Snethen JA, Broome ME. Weight, exercise, and health: children’s perceptions. Clin Nurs Res 2007;16:138–152.

24. Fox KR, Edmunds L. Understanding the world of the ‘fat kid’: Can schools help provide a better experience? Reclaim Child Youth 2000;9:177–181.

25. Neumark-Sztainer D, Story M, Faibisch L. Perceived stigmatization among overweight African-American and Caucasian adolescent girls. J Adolesc Health 1998;23:264–270.

26. Patton MQ. Qualitative Evaluation and Research Methods. Sage Publications: Newbury Park, CA, 1990.

27. Miles MB, Huberman AM. Qualitative Data Analysis. Sage Publications: Thousand Oaks, 1994.

28. Cole TJ, Freeman JV, Preece MA. Body mass index reference curves for the UK, 1990. Arch Dis Child 1995;73:25–29.

29. Berg BL. Qualitative Research Methods for the Social Sciences. Pearson Allyn and Bacon: Boston, 2004.

30. Smith JA, Osborn M. Interpretative phenomenological analysis. In: Smith JA (eds). Qualitative Psychology: A Practical Guide to Methods. Sage Publications: London, 2003, pp 51–80.

31. Smith JA, Osborn M, Jarman M. Doing interpretive phenomenological analysis. In: Murray M, Chamberlain K (eds). Qualitative Health Psychology: Theories and Methods. Sage Publications: London, 1999, pp 218–240.

32. Willing C. Introducing Qualitative Research in Psychology: Adventures in Theory and Method. Open University Press: Buckingham, 2001.

33. Creswell JW. Qualitative Inquiry and Research Design: Choosing Among Five Traditions. Sage publications: Thousand Oaks, 1998.

34. Wolcott HF. Transforming Qualitative Data: Description, Analysis, and Interpretation. Sage Publications: Thousand Oaks, 1994.

35. Department for Children, Schools and Families. Safe to Learn: Embedding Anti-bullying Work in Schools. <http://www.teachernet.gov.uk/wholeschool/ behaviour/tacklingbullying/safetolearn/> Accessed 24 April 2008.

36. Puhl R, Brownell KD. Ways of coping with obesity stigma: review and conceptual analysis. Eat Behav 2003;4:53–78.

37. Olweus D. Victimization by peers: antecedents and long-term outcomes.

In: Rubin K, Asendorf JB. Social Withdrawal, Inhibition, and Shyness in Children. Lawrence A Erlbaum Associates: Hillsdale, NJ, 1993, pp 315–341.

38. Harter S. The Construction of the Self: A Developmental Perspective.

Guilford Press: New York, 1999.

39. Storch EA, Masia-Warner C. The relationship of peer victimization to social anxiety and loneliness in adolescent females. J Adolesc 2004;27: 351–362.

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