Weight Stigma

Weight stigma is a form of social stigma that has been broadly defined as bias (prejudicial and negative attitudes, beliefs, and/or stereotypes) or discriminatory behaviors targeted at individuals with overweight or obesity or who are perceived to carry excess body weight.[1][2] Weight stigma is present in multiple domains, such as healthcare, education, media, and interpersonal settings, and is perpetrated by friends, family, and the individual him- or herself.[2]

Prevalence of Weight-Based Stigma and Discrimination

Researchers have found that over previous decades, the prevalence of reports of weight-based discrimination has increased 66%, rising from 7% in the 1990s to 12% in the 2000s.[3] Newer prevalence estimates, however, are needed. Comparatively, individuals with overweight and obesity as a group are rated more negatively than many other stigmatized groups, including sexual minorities and persons with mental illnesses.[4] Additionally, rates of weight-based discrimination have been found to be comparable to race-based discrimination, and among women, weight-based discrimination is the third most commonly reported source of discrimination, more prevalent than race-based discrimination.[5]

Unique Aspects of Weight Stigma

Weight stigma is a unique source of stigma for many reasons including the following:

  1. Many studies have evidenced that experiencing weight stigma may actually perpetuate behaviors associated with obesity, such as unhealthy eating behavior and lack of exercise (see "Physical Health and Physiological Consequences" below),[4][6] suggesting that experiencing weight stigma may exacerbate the condition eliciting stigma in the first place (i.e. overweight and obesity). This is not the case with other forms of stigma such as race stigma.
  2. Individuals with overweight and obesity are blamed for their obesity. However the literature broadly supports that sustained weight loss is extremely difficult and unattainable for most. Moreover, obesity is actually related to several inheritable genetic factors.[4]
  3. While many targets of bias and stigma are minorities, overweight and obesity actually comprise a numerical majority in the United States and in many other parts of the world.[7]
  4. Unlike other forms of discrimination, weight-based discrimination is not only legal (see “Policy” section below), but some government agencies and health policy scholars actually recommend promoting weight stigma as a treatment and intervention tactic for reducing obesity (see “Weight Stigma and Public Health: A Tool or a Threat?” below).
  5. Individuals with overweight and obesity do not receive in-group protection; in fact increased BMI is not associated with decreased weight bias,[8] and research has found that individuals with overweight and obesity actually show devaluation of their own in-group and prefer the out-group (i.e., thin people).
  6. An individual does not have to be obese to experience weight stigma, as even those who are normal weight by BMI standards can attribute discrimination or mistreatment to their body weight and therefore be a victim of the consequences of experiencing weight stigma.[9]

Domains of Weight Stigma

A 2009 review of the weight stigma literature by Puhl and colleagues identified that weight stigma is present in multiple settings including healthcare, education, interpersonal situations, multiple media forms and outlets, and across many levels of employment.[2] Ways in which weights stigma is present in these domains as well as downstream consequences will be elaborated upon in the following sections with evidence from several empirical review papers:

Employment

A recently published review of weight stigma in employment settings by Nowrouzi (2015) revealed that individuals with overweight and obesity face bias and discrimination in virtually all aspects of employment.[10] Nowrouzi's review along with one by Puhl and colleagues (2009) have found that this prevalent weight stigma manifests in multiple forms of employment discrimination towards employees with overweight and obesity. These include difficulty obtaining a job, worse job placement, lower wages and compensation, unjustified denial of promotions, harsher discipline, unfair job termination, and commonplace derogatory jokes and comments from coworkers and supervisors.[2][10] In their review, Puhl et al. find that employees with overweight and obesity report their weight as the most influential factor contributing to losing their job.[2] Another review by Giel and colleagues (2010) found that certain stereotypes about employees with overweight and obesity are highly endorsed by employers and supervisors, in particular that they have poorer job performance and that they lack interpersonal skills, motivation, and self-control.[11]

Healthcare

In their 2009 review, Puhl and colleagues found that many studies provide evidence supporting the notion that health professionals (including doctors, nurses, medical students, fitness professional, and dietitians) consistently endorse negative stereotypes about patients with overweight and obesity, in particular ascribing to them culpability for their weight status.[2] Weight stigma in the healthcare settings leads to impaired patient-provider communication, poorer doctor-patient relationships, poorer medical care and treatment (for example doctors spending less time with patients), and avoidance of the healthcare system all together on the part of the patient.[2] However, it is important to point out that the evidence that has been reviewed thus far comes primarily from self-report studies. Therefore, Puhl and colleagues concluded that research examining actual health outcomes is needed.[2] Overall, the impact of weight stigma in healthcare has become so problematic that many scholars have suggested that obesity-prevention programs should make minimizing stigma a priority.[2][12]

Education

Puhl and colleagues (2009) concluded from their review of weight stigma in education that this area still warrants further investigation, but that current trends indicate that students with overweight and obesity face barriers to educational success at every level of education.[2] Reviewed research demonstrates that educators, particularly Physical Education teachers, report antifat attitudes toward their students with overweight and obesity, which may undermine educational achievement.[2] Importantly, the education disparities for students with overweight and obesity appear to be strongest for students attending schools where obesity is not the norm. Several studies have evidenced that in environments such as these, students with overweight and obesity face greater educational disadvantages and are less likely to attend college, an effect that is particularly strong among women.[2] Moreover, weight stigma in educational settings also affects interpersonal relationships (see "Interpersonal Situations" below).[13]

Interpersonal Situations

Although a less studied topic than employment and healthcare, several studies reviewed by Puhl and colleagues (2009) provide evidence that women with overweight and obesity, in particular, face weight stigma from many interpersonal sources including family, friends, and romantic partners.[2] Another recent review by Puhl and Suh (2015) also documented that in school settings weight-based bullying is one of the most prevalent types of harassment reported by parents, teachers, and students.[13] Experiencing interpersonal weight stigma is related to myriad negative physics and mental health consequences (see "Physical and Mental Health Consequences of Experiencing Weight Stigma" below).

Media

Puhl et al. (2009) also reviewed how in entertainment, news reporting, and advertising, media is a particularly potent source of weight stigma. News reports have blamed individuals with overweight and obesity for various societal issues including prices of fuel, global temperature trends, and precipitating weight gain among their peers.[2] The literature also documents how in television programs, actors with overweight and obesity are often cast in minor roles, if at all. Programs also often depict them as the targets of teasing and derogation and often portray heavy characters displaying eating behaviors stereotypical to overweight and obesity.[2] This relatively low social status assigned to characters with overweight and obesity in television is also evidenced in children’s television, a tendency that perpetuates antifat attitudes among viewers.[2] In terms of media attention for obesity itself, a recent review by Puhl and Suh (2015) revealed that obesity-related media campaigns that used stigmatizing messages in fact undermine motivations and intentions to pursue healthy eating and exercise behaviors.[13]

Physical and Mental Health Consequences of Experiencing Weight Stigma

In both adults and children with overweight and obesity, several reviews of the literature have found that across a variety of studies, there is a consistent relationship between experiencing weight stigma and many negative mental and physical health outcomes.[2][4][6][13][14] These will be discussed separately in the sections below, although it should be noted that oftentimes physical and mental health consequences are intertwined, in particular those related to eating disorders.

Physical Health and Physiological Consequences

Papadopoulos and Brennan (2015) recently found that across many reviewed studies, relationships emerged between experiencing weight stigma and both BMI and difficulty losing weight in weight loss treatment seeking adults.[6] However the findings are somewhat mixed. They also report evidence that experiencing weight stigma is related to poor medication adherence. Among weight loss treatment-seeking adults, experiencing weight stigma might exacerbate weight- and health-related quality of life.[6] This review along with reviews by Vartanian and Smyth (2013) and Puhl and Suh (2015) have also found that across several studies and in both adults and children, experiencing weight stigma is related to decreased exercise behavior overall, as well as decreased motivation to exercise, decreased exercise self-efficacy, and increased food craving and tendency to overeat.[4][6][13] It is important to note that these effects of weight stigma on exercise and physical activity emerge independent of Body Mass Index, suggesting that weight stigma becomes a unique barrier to physical activity outside of barriers that may be associated with overweight and obesity in particular. Finally, across many studies, Puhl and Suh (2015) also found that that experiencing weight stigma is related to many physiological consequences as well, including increased blood pressure, augmented cortisol reactivity, elevated oxidative stress, impaired glycemic control/elevated HbA1c, and increased systemic inflammation,[13][14] all of which have notable consequences for physical health and disease.

Mental Health and Psychological Consequences

Broadly speaking, experiencing weight stigma is associated with psychological distress. Papadopoulos's 2015 review of the literature found that across several studies, this distress can manifest in anxiety, depression, lowered self-esteem, and substance use disorders, both in weight loss treatment seeking individuals as well as community samples.[6] Many empirical reviews have found that weight stigma has clear consequences for individuals suffering from eating and weight disorders (including Anorexia Nervosa, Bulimia Nervosa, and Binge Eating Disorder), as it plays a unique role, over and above other risk factors, in perpetuating disordered eating psychopathology.[6][13][14] These results have emerged in both adult and adolescent samples and among both men and women. Notably, the studies included in these reviews reported their results emerging over and above the degree of overweight/obesity in their respective subjects, suggesting that weight stigma, in particular, and not just being overweight or obese, precipitates these negative outcomes.

Policy

Over the past few decades, many scholars have identified weight stigma as a long-standing form of social stigma and one of the last remaining socially acceptable forms of prejudice. It follows then that individuals with overweight and obesity as targets still face uniquely socially acceptable discrimination.[15][16] This claim is substantiated at the policy level, where there is currently no federal legislation that protects individuals with overweight and obesity from employment-related discrimination.[10] Civil rights legislation such at Title VII of the Civil Rights Act of 1964 prohibits discrimination based on race and several other domains, but weight is not included in this act. At the local level, only one state in the US (Michigan) has policy in place for prohibiting weight-related employment discrimination and very few local municipalities have human rights ordinances in place to protect body size.[2][17] Typically, the only type legislation that individuals with overweight and obesity can cite in lawsuits is related to disability. For example, the Americans with Disabilities Act is one such avenue, but as Puhl et al. (2009) report, it is difficult for many individuals with obesity to qualify as disabled according to the criteria included in this statute.[2]

Weight Stigma and Public Health: A Tool or a Threat?

Although many health policy scholars and public health initiatives have suggested that weight stigma might motivate weight loss, the evidence from the existing literature largely does not support this notion. As cited above, experiencing weight stigma (both interpersonally as well as exposure to stigmatizing media campaigns) is consistently related to a lack of motivation to exercise and a propensity to overeat.[4][6][13] In a 2010 review examining whether weight stigma is an appropriate public health tool for treating and preventing overweight and obesity, Puhl and Heuer concluded that stigmatizing individuals with overweight and obesity is actually detrimental in three important ways: (1) it threatens actual physical health, (2) it perpetuates health disparities, and (3) it actually undermines obesity treatment and intervention initiatives.[18] In line with this, another recent review of the consequences of experiencing weight stigma, this one conducted by Puhl and Suh (2015), concluded that, considering the myriad negative physical and mental health consequences associated with experiencing of weight stigma, it should in fact be a target, instead of a tool, in obesity prevention and treatment.[13] These authors further recommend that a necessary first step in reducing weight stigma is raising a broader awareness of its negative consequences.[13]

References

  1. ↑ Puhl, Rebecca M.; Brownell, Kelly D. (2003-11-01). "Psychosocial origins of obesity stigma: toward changing a powerful and pervasive bias". Obesity Reviews 4 (4): 213–227. doi:10.1046/j.1467-789X.2003.00122.x. ISSN 1467-789X.
  2. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 Puhl, Rebecca M.; Heuer, Chelsea A. (2009-05-01). "The Stigma of Obesity: A Review and Update". Obesity 17 (5): 941–964. doi:10.1038/oby.2008.636. ISSN 1930-739X.
  3. ↑ Andreyeva, Tatiana; Puhl, Rebecca M.; Brownell, Kelly D. (2008-05-01). "Changes in Perceived Weight Discrimination Among Americans, 1995–1996 Through 2004–2006". Obesity 16 (5): 1129–1134. doi:10.1038/oby.2008.35. ISSN 1930-739X.
  4. 1 2 3 4 5 6 Vartanian, Lenny R.; Smyth, Joshua M. (2013-01-04). "Primum Non Nocere: Obesity Stigma and Public Health". Journal of Bioethical Inquiry 10 (1): 49–57. doi:10.1007/s11673-012-9412-9. ISSN 1176-7529.
  5. ↑ Puhl, Rebecca M.; Andreyeva, Tatiana; Brownell, Kelly D. (2008-03-04). "Perceptions of weight discrimination: prevalence and comparison to race and gender discrimination in America". International Journal of Obesity 32 (6): 992–1000. doi:10.1038/ijo.2008.22. ISSN 0307-0565.
  6. 1 2 3 4 5 6 7 8 Papadopoulos, Stephanie; Brennan, Leah (2015-09-01). "Correlates of weight stigma in adults with overweight and obesity: A systematic literature review". Obesity 23 (9): 1743–1760. doi:10.1002/oby.21187. ISSN 1930-739X.
  7. ↑ Ogden, Cynthia L; Carroll, Margaret D; Kit, Brian K; Flegal, Katherine M (26 February 2014). "Prevalence of childhood and adult obesity in the United States, 2011-2012.". JAMA 311 (8): 806–14. PMID 24570244.
  8. ↑ Latner, Janet D.; O'Brien, Kerry S.; Durso, Laura E.; Brinkman, L. A.; MacDonald, T. (2008-04-15). "Weighing obesity stigma: the relative strength of different forms of bias". International Journal of Obesity 32 (7): 1145–1152. doi:10.1038/ijo.2008.53. ISSN 0307-0565.
  9. ↑ Carr, Deborah; Friedman, Michael A. (2005-09-01). "Is Obesity Stigmatizing? Body Weight, Perceived Discrimination, and Psychological Well-Being in the United States". Journal of Health and Social Behavior 46 (3): 244–259. doi:10.1177/002214650504600303. ISSN 0022-1465. PMID 16259147.
  10. 1 2 3 Nowrouzi, Behdin (2015-06-17). "Weight Bias in the Workplace: A Literature Review". Occupational Medicine & Health Affairs 03 (03). doi:10.4172/2329-6879.1000206.
  11. ↑ Giel, Katrin Elisabeth; Thiel, Ansgar; Teufel, Martin; Mayer, Jochen; Zipfel, Stephan (2010-03). "Weight Bias in Work Settings – a Qualitative Review". Obesity Facts 3 (1): 33–40. doi:10.1159/000276992. Check date values in: |date= (help)
  12. ↑ MacLean, Lynne; Edwards, Nancy; Garrard, Michael; Sims-Jones, Nicki; Clinton, Kathryn; Ashley, Lisa (2009-03-01). "Obesity, stigma and public health planning". Health Promotion International 24 (1): 88–93. doi:10.1093/heapro/dan041. ISSN 0957-4824. PMID 19131400.
  13. 1 2 3 4 5 6 7 8 9 10 Puhl, Rebecca; Suh, Young (2015-04-01). "Health Consequences of Weight Stigma: Implications for Obesity Prevention and Treatment". Current Obesity Reports 4 (2): 182–190. doi:10.1007/s13679-015-0153-z. ISSN 2162-4968.
  14. 1 2 3 Puhl, Rebecca; Suh, Young (2015-02-05). "Stigma and Eating and Weight Disorders". Current Psychiatry Reports 17 (3): 1–10. doi:10.1007/s11920-015-0552-6. ISSN 1523-3812.
  15. ↑ Puhl, Rebecca; Brownell, Kelly D. (2001-12-01). "Bias, Discrimination, and Obesity". Obesity Research 9 (12): 788–805. doi:10.1038/oby.2001.108. ISSN 1550-8528.
  16. ↑ Stunkard, Albert J.; Sorensen, Thorkild I.A. (1993-09-30). "Obesity and Socioeconomic Status – A Complex Relation". New England Journal of Medicine 329 (14): 1036–1037. doi:10.1056/NEJM199309303291411. ISSN 0028-4793. PMID 8366906.
  17. ↑ Tehran, Elizabeth E. (2005). Legal theory on weight discrimination. In K. Brownell, R. Puhl, M. Schwartz, & L. Rudd (Eds.), Weight bias: nature, consequences, and remedies (pp. 195–211). New York, NY.
  18. ↑ Puhl, Rebecca M.; Heuer, Chelsea A. (2010-06-01). "Obesity Stigma: Important Considerations for Public Health". American Journal of Public Health 100 (6): 1019–1028. doi:10.2105/AJPH.2009.159491. ISSN 0090-0036. PMC 2866597. PMID 20075322.
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