Stigmatizing Images in Obesity Health Campaign Messages and Healthy Behavioral Intentions

Abstract

Background. Antiobesity campaigns blaming individual behaviors for obesity have sparked concern that an emphasis on individual behavior may lead to stigmatization of overweight or obese people. Past studies have shown that perpetuating stigma is not effective for influencing behavior. Purpose. This study examined whether stigmatizing or nonstigmatizing images and text in antiobesity advertisements led to differences in health-related behavioral intentions. Method. Participants in this experiment were 161 American adults. Measures included self-reported body mass index, weight satisfaction, antifat attitudes, and intention to increase healthy behaviors. Results. Images in particular prompted intention to increase healthy behavior, but only among participants who were not overweight or obese. Conclusion. Images and text emphasizing individual responsibility for obesity may influence behavioral intention among those who are not overweight, but they do not seem to be effective at altering behavioral intentions among overweight people, the target audience for many antiobesity messages. Images in antiobesity messages intended to alter behavior are influential and should be selected carefully.

Keywords

campaigns health communication obesity social determinants weight stigma

Public health advertising campaigns often seek to influence individual behavior by altering or reinforcing attitudes toward that behavior. Unfortunately, they may also stigmatize individual behavioral causes of health issues (Cho & Salmon, 2007). Weight stigma is defined as “negative attitudes toward a person because he or she is overweight or obese, such as the stereotype that obese persons are lazy or lacking in willpower” (Bartoshuk, 2010). With regard to antiobesity campaigns, some argue that messages blaming obese individuals mobilize social pressure to motivate people to change behavior (Callahan, 2013). However, weight stigma does not seem to encourage weight loss among overweight individuals (Puhl & Heuer, 2010). Priming the negative effects of weight stigma among individuals who perceived themselves as overweight led to lower self-efficacy and increased calorie consumption (Major, Hunger, Bunyan, & Miller, 2014). In another study, overweight women who viewed a video of weight-stigmatizing material consumed more calories than overweight women who viewed a neutral video and normal-weight women who viewed either video (Schvey, Puhl, & Brownell, 2011). Despite evidence of the harmful effects of weight stigma, antiobesity messages still use stigmatizing images to motivate behavior change among overweight individuals (Simmons-Duffin, 2012). Furthermore, these messages do not emphasize other factors that cause obesity, such as lack of opportunities for physical activity or the ready availability of cheap processed foods. Awareness of advertisements that emphasized corporate responsibility for tobacco use, the Truth campaign, was correlated with reduced smoking rates, but this strategy has not been tested with obesity (Niederdeppe, Farrelly, & Haviland, 2004). This study extends findings about the motivational effects of weight stigma by considering the effects of stigmatizing images as well as text. Specifically, this experiment tests whether different text–image combinations emphasizing individual versus social or structural causes of obesity led to differences in health-related behavioral intentions, and whether effects were moderated by weight status and weight satisfaction.

Images are a prominent and salient feature of persuasive messages. Visual elements in health communication campaigns may inadvertently perpetuate stigma toward the depicted group (Parrott, 2011). In antiobesity messages, images may tacitly or explicitly reinforce weight stigma by depicting overweight individuals in a dehumanizing or stigmatizing manner, for example, in revealing clothing, which emphasizes their physical size, or eating unhealthy foods, which may cue stereotypes of obese people as lazy or lacking willpower (Heuer, McClure, & Puhl, 2011; Puhl, Luedicke, & Peterson, 2013). Few studies have examined the effects of stigmatizing images and text in persuasive antiobesity messages (Puhl, Peterson, & Luedicke, 2013), but differently valenced images can influence attitudes or beliefs when text remains constant (Gibson & Zillmann, 2000; Puhl, Luedicke, & Peterson, 2013). Research on processing of news and persuasive messages suggests that visual imagery is potentially even more potent than text in conveying who is responsible for obesity and in perpetuating negative attitudes toward overweight individuals (e.g., Zillmann & Gan, 1996), but it is not yet known how stigmatizing images in the context of persuasive messages affect attitudes and behaviors.

Recent research has revealed that stigmatizing images of obese individuals led to negative attitudes about them (McClure, Puhl, & Heuer, 2011). Pearl, Puhl, and Brownell (2012) found that participants who viewed stigmatizing images felt more social distance from the individual depicted and had more stigmatizing attitudes toward obesity than did participants who viewed positive images of obese individuals. Thus, the study hypothesizes that participants who view antiobesity messages that include stigmatizing images of overweight people will have more negative attitudes toward obese individuals than participants who view ads that emphasize social rather than individual responsibility for obesity (Hypothesis 1). This research also asks whether antifat attitudes vary when participants view different combinations of images and text emphasizing social versus individual responsibility for obesity, and whether these effects are moderated by weight status (Research Questions [RQ] 1 and 2).

The priming effects of stigmatizing messages on behavioral intention have also been tested. In one study, stigmatizing antiobesity campaigns did not alter motivation to improve behaviors when compared with nonstigmatizing campaigns (Puhl, Peterson, et al., 2013). Priming weight stigma has also been found to have different effects based on perceived weight status (Schvey et al., 2011). Major et al. (2014) found that reading stories about weight stigma served as a social identity threat to women who perceived themselves as overweight—they had lower self-efficacy and consumed more calories than women who did not perceive themselves as overweight and women who read a control story. However, the authors found that exposure to weight stigma actually increased self-efficacy among participants who did not consider themselves overweight. A logical next step is to test whether messages that combine stigmatizing images of overweight individuals with text have the same effects on behavioral intention as text addressing weight stigma. Thus, the study asks whether exposure to stigmatizing images versus positive images of overweight people may have a boomerang effect among overweight individuals, as predicted in past studies of weight stigma, and whether exposure to stigmatizing images could in fact be motivating to individuals who are not overweight (RQ3).

Additionally, Major et al. (2014) suggest that people who are less satisfied with their current weight, whether or not they are actually classified as overweight according to body mass index (BMI), may be more likely to internalize messages from antiobesity ads than are participants who are not motivated to change their weight, regardless of BMI. Therefore this research asks, How does weight satisfaction moderate the effects of images and text on behavioral intention (RQ4), and are the effects of weight satisfaction on behavioral intention the same for normal weight versus overweight participants (RQ5)?

Method

Study Design

This study used a 2 (stigmatizing image vs. nonstigmatizing image) × 2 (text emphasizing individual behavior vs. social factors) between-participants experimental design.

Participants

A sample of 188 adults was recruited through the SocialSci.com survey website. SocialSci maintains an anonymous pool of participants who receive gift cards in exchange for research participation. Participants were eligible for inclusion if they were over older than 18 years of age and were residents of the United States.

Raw data were screened for univariate and multivariate outliers. Data were deleted from 1 participant with a BMI greater than 2 standard deviations away from the mean (BMI = 50), 12 participants who completed the study in fewer than 5 minutes, 9 participants who completed the study in more than 40 minutes, and 15 multivariate outliers (Mahalanobi’s distance > 20.515; based on all dependent variables and covariates). Data from the remaining 161 participants were included. Participant demographic information is provided in Table 1.

Table 1.

Participant Demographics.

Characteristic	No. (%) of participants (n = 161)
Gender
Female	86 (52.0)
Age (years)
M (SD)	31.1 (10.3)
Range	18-67
Race
White	125 (77.6)
Asian	16 (9.9)
Black	3 (1.9)
Latino	13 (8.1)
Other/don’t want to say	4 (2.5)
Marital status
Married or living with partner	85 (52.5)
Single, never been married	70 (43.2)
Divorced, widowed, or separated	6 (4.3)
Educational level
Some high school or high school diploma	14 (8.7)
Some college	45 (28.0)
College graduate or more	102 (63.3)
Employment status
Employed for wages or self-employed	109 (67.7)
Full-time student	31 (19.2)
Retired	2 (1.2)
Homemaker	10 (6.2)
Out of work or unable to work	9 (5.6)
Body mass index
<25.0	78 (48.4)
25.0-30.0	41 (25.5)
>30.0	42 (26.1)

Stimuli

Images

Images in advertisements were either stigmatizing images of overweight people or nonstigmatizing images that emphasized social determinants, or external causes, of obesity (see the appendix for examples of messages from each condition). The four stigmatizing images were like those identified in content analyses of obesity news coverage, which often feature close-up images of obese adults eating or with their eyes or head cut out of the image (Heuer et al., 2011). Nonstigmatizing images focused on social determinants related to the fast-food industry, suggested to be the social cause of obesity most salient to the public (Niederdeppe, Shapiro, & Porticella, 2011). Images depicted the ready availability of fast food or the prevalence of fast food marketing. In a pilot test, a convenience sample of 27 adults rated their agreement with whether each of the four images from each condition (1) blamed individuals and their choices for obesity and (2) blamed social or structural factors for obesity. Pilot test participants agreed that stigmatizing images of overweight people blamed individuals and their choices for obesity when compared with images of fast food, t(26) = 5.32, p < .001. Conversely, images of fast food were perceived as blaming social and structural factors for obesity when compared with stigmatizing images, t(26) = −3.32, p = .003.

Text

Two authors wrote four messages in each of the two text categories: individual determinants, which emphasized the role of individual behavior in obesity (e.g., “People have no self-control when it comes to junk food. They load up on fast food and sweets instead of eating fresh fruits and vegetables. Poor food choices cause obesity.”), and social determinants, which emphasized the role of food manufacturing or marketing in obesity (e.g., “Food companies make sure their junk food is cheap and available on every corner. Since junk foods are everywhere, people have no choice but to eat them more often. Food company practices are causing obesity.”). In the same pilot test, 27 adults agreed that the social determinants text blamed social and structural factors for obesity compared with text emphasizing individual behavior, t(26) = −3.36, p = .002, and that individual determinants text blamed individuals and their choices for obesity compared with the social determinants text, t(26) = −2.83, p = .003.

A graphic designer used InDesign software to construct all possible text and image combinations, which were then used as the experimental stimuli.

Procedure

Participants were randomly assigned to one of four conditions: (1) stigmatizing image and individual behavior text, (2) stigmatizing image and social determinants text, (3) fast food image and individual behavior text, and (4) fast food image and social determinants text. Variance tests showed that data met assumptions of equivalence of variance (Box’s M test for homogeneity of the covariance matrix, p = .35; Levene’s test for homogeneity of variance across dependent variables, all p > .10). Because there was a message repetition factor, participants each viewed four messages representing the same assigned condition (Reeves & Geiger, 1994). Four sequences of four text–image combinations were randomly selected to control for order effects, and no one saw the same text or image more than once. The target messages were alternated with control ads that had been pretested for neutral valence and arousal. After viewing messages in their assigned condition and control ads, participants were asked about their antifat attitudes, behavioral intentions, weight satisfaction, BMI, and demographic characteristics (age, race, gender, educational level, employment status, and marital status; Table 1). No measures were administered prior to the message exposure.

Dependent Variables

Attitudes Toward Obesity

Participants rated their level of agreement with statements describing positive and negative attitudes toward and stereotypes of obese and overweight persons on a scale from 1 (strongly disagree) to 5 (strongly agree; Antifat Attitudes Scale; Lewis, Cash, Jacobi, & Bubb-Lewis, 1997). Items included “Fat people don’t care about anything but eating” and “Fat people are just as competent in their work as anyone [reversed].” Reliability was high (Cronbach’s α = .89), so scores for all 13 items were averaged to create a single scale.

Behavioral Intentions

Two questions assessed health-related behavioral intention: “How likely are you to have five or more servings of fruits and vegetables on most days in the next year?” and “How likely are you to exercise at least 3 days during most weeks in the next year?” (1 = very unlikely, 5 = very likely; r = .35, p < .001, M = 3.68, SD = 1.00; Niederdeppe et al., 2011). The two items were averaged.

Moderator Variables

Body Mass Index

Normal weight versus overweight was operationalized as self-reported BMI, which has been shown to be a valid measure especially among adults younger than 60 years, who made up most of the sample (Kuczmarski, Kuczmarski, & Najjar, 2001; Spencer, Appleby, Davey, & Key, 2002). Self-reported weight (pounds) and height (inches) informed the autogenerated BMI measurement. Based on BMI, 78 participants (48.1%) were classified as normal weight—a term used here and elsewhere for those under the overweight threshold as determined by the Centers for Disease Control and Prevention (2011; BMI range: 16.3-24.6; mean = 21.4)—41 (25.3%) were overweight (BMI range: 25.0-29.8; M = 26.8) and 42 (26.1%) were obese (BMI range: 26.6-46.6; M = 35.0). The overweight and obese groups were combined in analysis to increase power.

Weight Satisfaction

Participants were also asked about their attitudes about their current weight: “How satisfied do you feel with your current weight?” (1 = very satisfied, 5 = very dissatisfied).

Data Analysis

Data were analyzed in SPSS19 using analysis of covariance and a Bonferroni correction for multiple comparisons. Age and gender were correlated with the dependent variables and were used as covariates. Other demographic variables (race, marital status) did not significantly influence dependent variables and were not included in the analysis. The PROCESS macro was used to investigate whether weight satisfaction moderated the effects of message by weight status (Hayes, 2013).

Results

Attitudes Toward Obese People

Participants’ attitudes toward obese individuals did not differ based on whether they saw stigmatizing images of overweight people or images emphasizing social determinants (p = .92; Hypothesis 1).

When text and image were considered together, however, there was a significant omnibus test, indicating differences between conditions, F(1, 161) = 4.40, p = .03, partial η² = .03. However, no post hoc comparisons were significant (p > .10 for all). Data trends indicate that participants who saw messages with text and images emphasizing the same causal factors, that is, text emphasizing personal responsibility and stigmatizing images (M = 1.85, SD = 0.79; p = .13), as well as participants who saw messages with text and images emphasizing social determinants of obesity (M = 1.88, SD = 0.86; p = .11) had slightly more negative attitudes toward obese individuals than did participants who saw messages with images and text emphasizing different causal factors, that is, stigmatizing images and text emphasizing social determinants of obesity (M = 1.63, SD = 0.61; RQ1).

Overall, normal-weight participants had more negative attitudes toward obese individuals (M = 1.95, SD = 0.80) than did participants whose BMI classified them as overweight or obese (M = 1.62, SD = 0.65), F(1, 161) = 8.14, p = .005, partial η² = .05. However, weight status did not moderate the effects of images or of any text–image combinations on attitudes toward obese people (p > .40 for all comparisons; RQ2).

Behavioral Intentions

There were three important findings about behavioral intentions. Priming normal-weight participants with stigmatizing images increased their agreement that they planned to eat healthier and exercise in the next year. Normal-weight participants who viewed stigmatizing images of overweight people were slightly more likely to express intentions to perform healthy behaviors in the next year (M = 4.10, SD = 0.97) than those who viewed images of fast food (M = 3.43, SD = 0.91), F(3, 161) = 2.08, p = .05, partial η² = .04. No other post hoc comparisons were significant, and the effect of text alone was not significant (p > .15 for all). Image condition or text condition alone had no effect on behavioral intention among overweight individuals.

There was no three-way interaction on healthy behavior for text and image among overweight participants (p = .47). However, there was a three-way interaction among normal-weight participants, F(3, 161) = 2.71, p = .05, partial η² = .05 (Figure 1). Results of post hoc tests demonstrated that normal-weight participants who viewed ads with stigmatizing images and text emphasizing individual responsibility for obesity were more likely to express intentions to perform healthy behaviors (M = 3.97, SD = 0.99) than those who saw images of fast food and text emphasizing individual responsibility for obesity (M = 3.28, SD = 0.98, p = .02).

Figure 1.

Effects of image and text condition on intention to increase healthy behaviors among normal-weight individuals.

Similarly, participants who saw stigmatizing images and text emphasizing social determinants (M = 4.27, SD = 0.94) were more likely to agree they would perform healthy behaviors than were participants who saw images of fast food and text emphasizing social determinants (M = 3.61, SD = 0.92; p = .05). Finally, in messages that combined an image or text stigmatizing obese individuals and their behavior with an image or text emphasizing social factors, image condition also seemed to exert more influence than text condition on behavioral intention. Participants who viewed messages combining a stigmatizing image with text emphasizing social determinants (M = 4.27, SD = 0.94) expressed greater intention to perform healthy behaviors than participants who viewed messages combining an image of fast food with text emphasizing individual responsibility for obesity (M = 3.28, SD = 0.89; p = .003).

Without accounting for weight status (normal/overweight/obese), satisfaction with weight did not moderate the effect of image or text condition on behavioral intention (p > .38 for all comparisons; RQ4). However, among normal-weight participants, weight satisfaction did moderate the effects of stigmatizing versus fast food image on intentions to increase healthy behavior (Figure 2; RQ5). The PROCESS macro assesses the effect of continuous moderators at the mean value ±1 SD. Normal-weight participants who were less satisfied with their current weight were significantly more likely to agree they intended to increase healthy behavior in the next year if they viewed stigmatizing images of overweight individuals versus images of fast food (mean weight satisfaction: Β = 0.94, SE = 0.37, t = 2.52, p = .01, 95% confidence interval [0.20, 1.68]; mean +1 SD weight satisfaction: Β = 1.19, SE = 0.54, t = 2.18, p = .03, 95% confidence interval [0.11, 2.26]). There were no other significant differences found when comparing text conditions or text-image combinations.

Figure 2.

Weight satisfaction moderates the effect of stigmatizing images on intention to increase healthy behaviors among normal-weight individuals.

Discussion

Stigmatizing individuals may be an unintended consequence of health communication campaigns, while stigmatizing behaviors, such as smoking or soda consumption, may be an intended consequence (Puhl, Peterson, et al., 2013). This experiment examined the effects of images that stigmatized overweight individuals and text that stigmatized individual behavior compared with images and text that emphasized social determinants of obesity, like fast food marketing. The effects of antiobesity messages on behavioral intentions were moderated by weight status. While behavioral intention did not vary as a function of message among overweight participants, images in particular prompted differences in behavioral intentions among those whose BMI classified them as normal weight. This study supports previous research that messages about weight stigma may serve as fear appeals among people who are not overweight (Major et al., 2014). Health messages that use fear to encourage behavior change have been shown to be effective only when people already believe that they can complete the behavior in question. In this study, stigmatizing images seem to be priming an avoidance response among normal-weight individuals, prompting them to increase healthy behaviors in order to avoid the stigmatized condition.

The relatively stronger effect of images versus text has been demonstrated in previous research (Gibson & Zillmann, 2000; Zillmann & Gan, 1996), and suggests that additional work is needed to investigate the consequences of images used in persuasive health communication. In this study, stigmatizing images influenced behavioral intention among normal-weight individuals, even when text explicitly blamed social determinants. Major et al. (2014) found that participants who did not perceive themselves as overweight had increased self-efficacy for maintaining a healthy weight after reading a story about weight stigma in the workplace. Exposure to stigmatizing messages might thus affect behavioral intention among normal-weight individuals by increasing motivation to avoid obesity or by triggering downward comparisons, which reinforce self-efficacy because audiences perceive themselves as being effective at weight control compared with the overweight individuals depicted in the message. The moderating effect of low-weight satisfaction among normal-weight individuals provides some evidence for the former of these two explanations. Normal-weight participants who were nonetheless dissatisfied with their weight were more likely to express intentions to exercise and eat healthier if they saw stigmatizing images than if they saw images of fast food. Among normal-weight individuals who were also motivated to lose weight, stigmatizing images may prime negative emotions related to weight stigma. This suggests that weight satisfaction may predict the salience of weight stigma even among individuals not classified as overweight based on BMI.

It is noteworthy that message condition had no significant effects among overweight individuals, the likely target audience for many antiobesity messages. Results suggest that stigmatizing images are no more, or less, effective at altering behavioral intention than images emphasizing other factors contributing to obesity. Other studies have demonstrated a boomerang effect. Priming weight stigma actually leads to greater calorie consumption among overweight individuals (Major et al., 2014; Schvey et al., 2011). The lack of this effect in this study could be due to the brevity of the manipulation or to the use of self-report dependent variables, which are more susceptible to social desirability bias.

There were no significant differences in attitudes based on images, which could be a function of a ceiling effect for the scale used or a lack of strength in the manipulation, since several other studies have shown attitude effects from stigmatizing images. However, an omnibus test did provide limited evidence that messages that emphasize both individual and social determinants are preferable to messages that emphasize only social determinants, a finding that aligns with recent research on narrative persuasion. Narratives that addressed both individual and social determinants of obesity led to less counterarguing and more empathy than narratives that emphasized only social determinants (Niederdeppe, Roh, & Shapiro, 2015). In this study, messages with text and images that emphasized only individual or social responsibility were associated with the most negative attitudes toward obese individuals, though it seems that the study lacked sufficient power to detect any significant differences.

Limitations and Future Research

This study has several limitations that restrict generalizability but suggest opportunities for future research. First, it did not include a control group who saw no messages, so it is not possible to compare antifat attitudes after viewing experimental stimuli to a baseline or control value. In addition, while previous work suggests susceptibility to weight stigma may differ by race, this sample was not diverse enough to test this relationship. Other methodological limitations include the use of an online sample, which required use of self-reported weight. Self-reported BMI is consistently underestimated, and correlation between self-reported and measured height and weight may also vary by age and gender (e.g., Krul, Daanen, & Choi, 2011). In addition, our measure of behavioral intention included only two items. While the results suggest stigmatizing images may serve as fear appeals, it was not a contention original to the study; therefore, measures that are considered best practices for fear appeal research, such as measuring actual behavior (Witte, 1994), were not included. Future studies should include cognitive mediators such as self-efficacy to model the relationship between messages and more robust measures of behavioral intentions. Additional research into the effects of stigmatizing images in persuasive messages, and how the effects of those messages are moderated by factors such as weight status or weight satisfaction, is needed.

Implications for Practice

This research has several implications for the practice of health communication. Health messages are seen as an important tool for combating rising obesity rates (Institute of Medicine, 2012). In the United States, these campaigns are created and disseminated by a range of organizations, from federally funded health organizations, such as the National Institutes of Health, to municipal or state public health agencies and organizations, such as Children’s Healthcare of Atlanta, which developed the Strong4Life campaign against childhood obesity that was recently criticized for its stigmatizing and stereotypical portrayals (Simmons-Duffin, 2012). This study suggests that images have effects in antiobesity messages, regardless of text. While these images might be effective as scare tactics in prevention campaigns, they are likely ineffective in treatment campaigns geared toward overweight individuals. As previous research suggests, stigmatizing images may also contribute to stereotyping of overweight individuals. The potential for negative effects of stigmatizing images suggests that best-practice guidelines for developing messages could be more widely disseminated among public health organizations. Because text encouraging individuals to make healthy choices is more effective than text perceived as stigmatizing (Puhl, Luedicke, & Heuer, 2013), text in antiobesity messages aimed at changing behaviors among overweight individuals should be gain-framed. These results suggest that the accompanying images should also be positively framed to depict benefits gained from behavior change rather than negatively framed to prime weight stigma. Future research should investigate which images are most effective at attracting attention to behavior change messages without perpetuating negative attitudes toward obese individuals.

Footnotes

Appendix

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

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