Background
Obesity is one of the leading public health concerns in the United States, presenting a considerable threat to the well-being and health of school-aged youth. Recent statistics illustrate that obesity rate remains high among children and adolescents: while about 1 in 5 reported to be obese or overweight based on the body mass index (BMI), hereafter referred to as BMI, those aged from 12 to 19 years with extreme obesity increased to slightly over 9% during the past two decades [
1]. Such prevalence of obesity may lead to deleterious health problems, physically [
2,
3] and psychosocially [
4‐
6].
Obesity in childhood and adolescence has been linked to a wide array of physical health outcomes. Specifically, obesity-related physical health symptoms include, but not limited to, headaches, stomachaches, somatic complaints, sleep difficulties, and school/social functioning [
7‐
9]. School children and adolescents with obesity also suffer from psychological and emotional problems such as depression [
10], anxiety [
11], low self-esteem [
12], and lack of emotional support and cognitive stimulation [
13].
Further, obesity during childhood and adolescence has been shown to be stigmatizing and likely to result in social adversity. There is a strong bias and prejudice towards school children with obesity [
14]. Obese children are perceived as the least favorable classmates by their peers in school [
15] and often labeled with various negative stereotypes [
16]. The weight-based prejudice from peers may be formed as early as three years of age [
17]. Upon entering elementary school, obese and overweight youth are likely to experience weight-related judgement and social outcomes such as rejection from peers or loss of friends [
18‐
20]. In addition, research indicates that stigma and attitude based on weight bias could originate from educators such as teachers [
21,
22] or parents and siblings [
23].
The weight-based stigma and hostility is also pervasive in the on-line domain. A qualitative analysis of social media content (e.g. Twitter) illustrates a prominent theme of offensive and prejudiced attitude and perception towards the notion of obesity [
24]. Among a wide range of stigmatizing content, obese individuals are perceived largely as gluttonous, unattractive, and sedentary [
25]. Based on a person’s weight or body size, youthful victims are stereotyped in a discriminatory, biased manner.
In addition to biased perceptions of one’s weight, prior research suggests that being obese or overweight contributes to the likelihood of becoming a victim of traditional bullying [
26]. Prior studies examining the impact of BMI on peer victimization found that overweight and obese children were more likely to be victimized by specific forms of bullying (verbal, relational, physical) compared to those with normal weight [
27,
28]. A related study, based on reports from teachers, mothers, and student themselves, showed a significant relationship between being obese and the odds of being bullied among sixth grade children, after controlling for sociodemographic characteristics [
19]. Given the widespread bias towards obesity, overweight children were more likely to experience weight-specific teasing perpetrated by peers in general compared to non-overweight children [
29].
More specifically, children have witnessed their overweight or obese peers to experience teasing in public area and during physical activities, exclusion from social activities, spreading of negative rumors, verbal threats and physical harassment [
30‐
32]. This appears to be consistent across gender; both obese boys and girls had a higher probability of becoming victims of overt forms of bullying (e.g. hitting, shoving, name-calling) than their average weight peers [
33]. However, other research has revealed that while females were primarily victims of verbal and relational bullying, males were more likely to be victims of all types (including verbal, physical, social exclusion, rumor spreading, and cyber bullying) [
34].
Despite only a few empirical findings, the stigmatization of being obese or overweight and risk for peer victimization are evident in cyberspace. In a study using a sample of school adolescents seeking weight loss treatment, more than half of the participants reported that they experienced weight-based cyberbullying victimization via computers or cell phones [
28]. While 61% of these youth have encountered on-line posting of embarrassing content, 59% have received mean text messages, e-mails, or instant messages. According to a more recent study of patients in residential facilities for severe obesity, obese adolescents were significantly more likely to be bullied via the Internet compared to their normally weighted peers [
29]. Furthermore, body dissatisfaction is correlated with cyberbullying victimization; youth who are victims of cyberbullying are twice as likely to perceive one’s body to be ‘too fat’ compared to those who have not been victimized [
30]. Given the stigma and bias associated with obesity and the greater visibility of offensive comments or images via social media [
25,
31,
32], weight-based victimization in online settings can be detrimental to the psychological and physical health of adolescents.
Prior studies have shown that adverse outcomes and responses are associated with weight-based victimization among school children. While adolescents who have been victims of weight-based teasing or bullying tend to feel depressed, sad, angry, afraid, and dissatisfied with their body, some are more likely to have negative reactions in and outside school such as avoidance strategies, binge eating, skipping schools, poor academic performance in the event of teasing or bullying by peers [
33]. Traditional bullying victimization is found to be associated with poor physical health, including somatic symptoms and withdrawn behaviors [
34,
35]. Similarly, cyberbullying negatively impacts the emotional and psychosocial well-being of those who are victimized. Specifically, victims of cyberbullying can suffer from social anxiety [
36], depressive symptoms [
37], decreased self-esteem [
38], suicidal thoughts [
39], emotional distress [
40], sadness [
41], and angry feelings [
42]. Moreover, being victimized on-line undermines one’s academic performance in school [
43], and further triggers problematic behaviors such as truancy [
38], alcohol use and weapon carrying [
44]. Furthermore, obese adolescents who have been victims of cyberbullying showed a higher level of suicidal ideation compared to their peers with normal weight [
29].
Notwithstanding findings indicating a strong relationship between bullying victimization and physical or psychological health, only a handful of studies have examined the longitudinal relationship between these factors. Involvement in traditional and cyber forms of bullying was found to be related to mental health and psychosocial problems such as depressive and emotional symptoms, social anxiety, ADHD symptoms, and lower levels of well-being [
45‐
50]. Similarly, minimal attention has been devoted to the longitudinal investigation of obesity and overweight with bullying behaviors. While a significant association between childhood obesity and the likelihood of being bullied was observed [
19] among sixth grade children, bullying victimization during adolescence was linked to an increased risk of obesity and higher BMI when reaching young adulthood [
51,
52]. The question emerging from these longitudinal findings concerns whether bullying victimization could be mediating the relationship between weight status and physical and psychological outcomes.
To date, no studies have examined the mediating role of bullying victimization in the relationship between obesity and both physical and psychological distress. Considering that adolescent obesity is correlated with a greater likelihood of being victimized, understanding the effect of victimization, both off-line and on-line, on one’s level of physical and psychological distress would be of particular value in developing treatments for victims to cope with their distress. The current study addresses the following research questions.
1)
To what extent do overweight and obese youth experience traditional and cyberbullying victimization, compared to normal weight youth?
2)
To what extent do overweight and obese victims of traditional or cyberbullying experience physical and psychological distress compared to normal weight youth?
3)
Does becoming a victim of either traditional or cyberbullying mediate the relationship between BMI and physical / psychological distress?
Discussion
A number of findings emerged from the current study. First, obesity, measured by BMI, showed a significant direct effect on one of the two types of victimization –traditional bullying. In line with prior research [
26‐
28,
65,
66], obese or overweight youth are significantly more likely to be victimized by bullying compared to those who are not obese. Contrary to the earlier findings suggesting a positive association between obesity and cyberbullying victimization [
28,
29], there was not a significant effect of BMI on the probability of being bullied on-line.
In light of previous research documenting the effect of obesity on physical and psychological distress, statistical evidence was found for a significant link between BMI and both forms of distress. In general, prior obesity research shows that children with obesity had a greater likelihood of exhibiting poor physical and psychological health outcomes [
2,
7,
8,
12,
13,
67]. Regarding the impact of victimization on distress, traditional bullying victimization was positively linked to physical and psychological forms of distress. This is consistent with previous research and suggests that youth who have been victims of traditional bullying are more likely to experience a variety of physical and psychological symptoms [
33‐
35]. Yet, an unexpected finding is the negative effect of cyberbullying victimization on psychological distress. Unlike prior studies [
36,
40,
41], our study found that youth who have been a victim of cyberbullying are less likely to experience psychosocial distress. One possible explanation may be that individuals may be involved as both victims and perpetrators of cyberbullying and also engage in aggressive behavior as a coping or defense strategy [
68‐
70]. This may contribute to lower levels of psychological distress. Moreover, youth with high levels of self-control showed greater levels of resiliency and lower levels of distress in response to real world or cyberbullying [
71]. Finally, peers may serve as a protective role in buffering the negative link between cyberbullying victimization and distress [
72].
Notably, mediating effects of bullying victimization were observed using the SUR approach. Only traditional bullying victimization mediated the link between BMI and physical distress. In addition, the association between BMI and psychological distress among youth was mediated by both forms of victimization. While traditional bullying victimization had a positive mediating effect on the BMI-distress link, cyberbullying victimization indicated a negative effect in the analysis. These indirect effects imply that obese or overweight youth who have been victims of traditional bullying would justifiably experience a higher level of physical and psychological distress. Overall, these results offer evidence that there may be further mediating link between BMI, bullying victimization and distress, which warrants further exploration.
The negative mediating effect of cyber victimization on the association between BMI and psychological distress could be explained in several ways. First, the measures for cyberbullying victimization may not fully capture the intricacies of how technology could be subverted to damage a victim’s reputation, self-esteem, or friendship. Rather, it merely reflects the location of bullying using a computer or cell phone. Moreover, victimization may not necessarily lead to emotional distress if it takes place in virtual realm [
73]. Given the unique properties of online environments [
74], it is plausible that obese or overweight victims may receive social support from bystanders via social media (e.g. Facebook), which, in turn, could neutralize negative comments from peers during weight-based cyberbullying incidents [
31]. For instance, if a youth receive a demeaning message or image related to obesity or overweight, an empathetic bystander could dissent (rather than conform to) the negative content made by others, which may be accompanied by reduced distress. Finally, the children in the current sample may not be considered “pure” victims. Since physical dominance is less visible in on-line interactions, it is possible that victims of traditional bullying could engage in aggressive behaviors towards those who have bullied them via electronic means in seeking retribution [
75,
76].
Strengths and limitations
The current study has a number of limitations. First, the results do not allow to draw causal inferences due to the cross-sectional nature of this study. Longitudinal studies are needed to disentangle the temporal relationship between the variables under study. Second, the measure for cyberbullying victimization may not accurately represent the ways in which an individual may be harassed or bullied via the Internet. Cyberbullying could be facilitated via a wide range of on-line platforms such as chat rooms, emails, text messages, mobile phone call, photo or video clip, and social media [
77‐
79]. Future research should consider a more comprehensive measure of cyber victimization to allow for a thorough evaluation of the on-line victimization experience. At the same time, there is need to establish a commonly agreed definition of cyber victimization for ensuring reliability to some degree [
80]. In addition, since the current study focused only on victims of weight-based bulling, future research could benefit from exploring the subgroup of bully-victims, who have been found to be more common in cyberbullying [
81] as opposed to traditional bullying [
82,
83]. Lastly, the present study utilized self-reported questionnaire and hence is subject to response bias.
Our study offers several strengths. First, the dataset used in this study consists of a nationally representative sample of U.S. youth, which enhances generalizability and statistical power and lessens selection bias. Second, despite its deficiency, BMI is considered to be well-validated and widely used by obesity researchers, and further proven to be of good predictive value [
84‐
86]. Third, the use of seemingly unrelated regression (SUR) and Sobel-Goodman tests allows one to assess the extent and significance of the mediating effects of traditional and cyber victimization in the link between weight status and both types of distress. Furthermore, the present findings offer useful insights into the mechanism indirectly linking indicators of obesity to physical and psychological distress via victimization. Yet, future research is needed to untangle the impact of on-line victimization on the link between obesity and psychological distress.