- Email: [email protected]
Weight discrimination and bullying
Best Practice & Research Clinical Endocrinology & Metabolism 27 (2013) 117–127
Contents lists available at SciVerse ScienceDirect
Best Practice & Research Clinical Endocrinology & Metabolism journal homepage: www.elsevier.com/locate/beem
2
Weight discrimination and bullying Rebecca M. Puhl, PhD, Director of Research, Senior Research Scientist *, Kelly M. King, MPH, Research Associate Rudd Center for Food Policy and Obesity, Yale University, 309 Edwards Street, New Haven, CT 06511, USA
Keywords: obesity bias stigma social consequences victimization youth
Despite significant attention to the medical impacts of obesity, often ignored are the negative outcomes that obese children and adults experience as a result of stigma, bias, and discrimination. Obese individuals are frequently stigmatized because of their weight in many domains of daily life. Research spanning several decades has documented consistent weight bias and stigmatization in employment, health care, schools, the media, and interpersonal relationships. For overweight and obese youth, weight stigmatization translates into pervasive victimization, teasing, and bullying. Multiple adverse outcomes are associated with exposure to weight stigmatization, including depression, anxiety, low selfesteem, body dissatisfaction, suicidal ideation, poor academic performance, lower physical activity, maladaptive eating behaviors, and avoidance of health care. This review summarizes the nature and extent of weight stigmatization against overweight and obese individuals, as well as the resulting consequences that these experiences create for social, psychological, and physical health for children and adults who are targeted. Ó 2013 Elsevier Ltd. All rights reserved.
Introduction The health impacts of obesity have received significant attention by researchers, health professionals, and policy makers, leading to an increased recognition of the importance of focused prevention and treatment of obesity and its related comorbidities. However, often absent in the national discourse of obesity are the negative outcomes that obese children and adults experience as a result of bias, stigma, and discrimination. Overweight and obese persons are highly stigmatized in our society, and weight-based stereotypes remain widespread including perceptions that obese persons are lazy, unmotivated, incompetent, noncompliant, sloppy, lacking in self-discipline, and lacking in willpower.1,2 * Corresponding author. Tel.: þ1 203 432 7354; Fax: þ1 203 432 9674. E-mail address: [email protected] (R.M. Puhl). 1521-690X/$ – see front matter Ó 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.beem.2012.12.002
118
R.M. Puhl, K.M. King / Best Practice & Research Clinical Endocrinology & Metabolism 27 (2013) 117–127
The social acceptability of these stereotypes often lead to overt forms of prejudice and discrimination, including inequities in employment settings, disparities in health care, and disadvantages in education, see Ref.2 In the United States, the prevalence of weight discrimination has increased by 66% in the last decade,3 and is now comparable to and in some cases exceeds racial discrimination.4 Given the prevalence of overweight and obesity in the American population, the number of children and adults potentially faced with stigmatization is immense. The consequences of being denied jobs, disadvantaged in education, marginalized by health care professionals, or victimized by peers because of one’s weight can have a profound impact on quality of life, and may even lead to behaviors that reinforce obesity. This review summarizes the nature and extent of weight stigmatization against overweight and obese individuals, as well as the resulting consequences that these experiences create for social, psychological, and physical health for children and adults who are targeted. Documentation of weight stigmatization Although negative stigmatization toward overweight and obese persons has been documented in published research for over fifty years, this topic has only begun to receive focused attention in the obesity field in the last decade.1 Findings from population-based studies, experimental research, longitudinal and cross-sectional work all point to consistent stigma and discrimination against obese persons in multiple domains of living. The continued social acceptability of weight stigmatization leaves overweight and obese persons vulnerable to stigmatization in the workplace, health care settings, educational institutions, the media, and even in interpersonal relationships with their family members and friends.2 Of additional concern is the frequency and impact of bullying and victimization toward obese youth, who are especially vulnerable to the negative consequences of weight-based stigmatization.5 The evidence in each of these areas is summarized below. Employment Overweight and obese employees face frequent discrimination in the workplace. Considerable experimental research shows that compared to thinner employees with identical qualifications, overweight and obese employees face discriminatory hiring practices, are denied promotions, face wrongful termination, and are stigmatized by colleagues and supervisors because of their weight.6 Recent research by Giel and colleagues (2012) found that individuals in charge of hiring underestimated the occupational prestige of obese individuals and were more likely to disqualify them from being hired.7 In some cases, hiring managers report more willingness to hire a less qualified thinner candidate, than a more qualified overweight candidate.8 Disparate treatment likely stems from negative weight-based stereotypes such as beliefs that obese employees are less conscientious, agreeable, emotionally stable, and extraverted than normal-weight colleagues despite a lack of validity to these claims.9 Obese employees also receive lower wages than thinner individuals for the same work performed,10 with some research showing that obese women earn 6% less than healthy weight women, and obese men earn 3% less than thinner men.11 This obesity wage penalty has been documented across all race and gender groups, with the exception of African American men and women.12 It has been estimated that for women, every one unit increase in Body Mass Index (BMI) is associated with a 1.83% drop in hourly wages.13 Reports of employment discrimination among obese persons parallel the above findings. In a nationally representative sample of 2838 Americans, compared to non-overweight individuals, overweight persons were 12 times more likely to report employment discrimination; obese persons were 37 times more likely to report employment discrimination, and severely obese persons were 100 times more likely to report employment discrimination.14 Similar findings have been reported in other national samples15 and among obese women who report high levels of weight stigmatization from supervisors and co-workers.16 Health care Weight bias also extends to the health care setting, where overweight and obese patients are vulnerable to stigmatization from health providers. Studies have consistently documented that
R.M. Puhl, K.M. King / Best Practice & Research Clinical Endocrinology & Metabolism 27 (2013) 117–127
119
medical professionals (e.g., physicians, nurses, medical students, and other health professionals) hold negative stereotypes about overweight patients, see Ref.17 including perceptions that obese patients are lazy, noncompliant, undisciplined, and have low willpower.2 One study of over 620 primary care physicians found that over half of doctors ascribed traits like, awkward, unattractive, ugly and noncompliant to obese patients, while one-third categorized them as weak-willed, sloppy and lazy.18 Further, physicians exposed to patients with higher body mass index (BMI) reported having less respect for their patients, having less ability or desire to help their patients, and reported treating obesity was “more annoying” and a greater waste of their time.19,20 Such negative beliefs persist, even for health professionals who specialize in the treatment of obesity.21 Despite evidence that physicians hold perceptions that obese patients are noncompliant with medical advice, or lack the willpower to make lifestyle changes,22 recent research has challenged these assumptions and shows that patients’ reported levels of motivation for weight loss are significantly higher than physicians’ opinions.23 Ultimately, the mismatch between doctors’ perceptions and patients’ lived experiences may compromise the patient–provider relationship and hamper communication around healthy behavior change.24 Obese patients additionally report feeling disrespected, dismissed, and upset about comments made by heath providers because of their weight.25 In a selfreport study of 2449 overweight and obese women, 69% specifically reported being stigmatized about their weight from a doctor, and 52% reported this occurring multiple times. Thus, poor communication and perceived stigma in medical settings may impede access to preventative care for obese patients.26 Weight stigma may also partially explain why many physicians fail to counsel obese patients about their weight.27 Overweight and obese patients who do receive medical counseling, however, have more realistic perceptions of their weight, increased desire to lose weight and more recent attempts at weight loss, providing even further evidence as to why stigma reduction in the health care sector is crucial to the health of overweight and obese persons.28 Education Overweight and obese students experience weight stigmatization from peers and educators in educational settings.2 Negative weight-based stereotypes toward obese students have been increasingly reported by educators.29 Research demonstrates that teachers hold biased perceptions about overweight youths’ abilities, viewing them to have poorer social, reasoning, physical, and cooperation skills than nonoverweight students, as well lower expectations for overweight students across a range of performance areas.30 Such biases may limit the educational opportunities available for overweight students. A recent study by Burmeister et al., 2012 found that students with higher BMIs were significantly less likely than average weight peers to receive offers of admission to psychology graduate programs after completing the interview process, despite receiving more positive letters of recommendation overall.31 Obese students also report awareness of weight bias from educators,32 with previous work documenting that over a third of overweight and obese women (N ¼ 2449) reported experiencing weight stigmatization from a teacher or educator, with over 20% indicating that such experiences occurred on multiple occasions.16 Recent work has further demonstrated that experiences of weight-based teasing mediate the relationship between poor school performance and body mass index among school children.33 More work is needed in this area to determine the nature and extent to which weight stigma contributes to disparate educational outcomes among overweight students and their thinner peers. Media The social acceptability of weight stigma is readily apparent through the negative depiction of overweight and obese persons in television and film, see Ref.34 Within both child and adult entertainment, overweight individuals are more likely to be cast as minor characters, the targets of ridicule and humor, depicted engaging in stereotypical behaviors (e.g., eating or bingeing on unhealthy foods), and are less likely to be portrayed as having romantic partners or interactions with friends,35 while thin characters take on central roles and are assigned positive characteristics. Content analyses of male and female television characters have found that heavier women receive significantly more negative comments from male characters, while heavier male characters are more likely to make negative
120
R.M. Puhl, K.M. King / Best Practice & Research Clinical Endocrinology & Metabolism 27 (2013) 117–127
references about their own weight, with both types of commentary often reinforced with audience laughter. Similar findings exist in children’s media. A study of 1221 cartoons with over 4000 cartoon characters revealed that overweight characters were more likely to be portrayed as having socially undesirable traits compared to average weight or underweight characters who were portrayed positively.36 Specifically, overweight characters are often portrayed as more aggressive, anti-social, evil, unattractive, unfriendly, disliked by others, and eating food compared to thinner characters who are depicted as being sociable, kind, successful, popular, attractive, and happy.37 Obese individuals are also negatively stereotyped in news media, and have been implicated in national stories as being responsible for increasing fuel prices,38 global warming39 and social contagion of obesity.2,40 Research has documented that the news media often frames obesity as an issue of personal responsibility, prioritizing overeating and lack of exercise as key explanations, over genetic, environmental or socioeconomic factors that may contribute to overweight. An analysis of 751 obesity related articles published in the New York Times between 1990 and 2001 revealed that the majority of news stories blame individuals for obesity and resulting moral panic. Similar to entertainment media, overweight people in news media were characterized by negative traits such as “stupid,” “ugly,” “naïve,” “irresponsible,” “lazy”, “greedy,” “without manners,” and “repugnant.”41 Moreover, a recent content analysis of online news imagery revealed that 72% of images portrayed overweight and obese individuals in a stigmatizing manner.42 Individuals who view negative photographs in news media display more negative attitudes toward obese people,43 suggesting that using more positive media portrayals of obese persons that challenge common stereotypes may help reduce negative societal stigma. Interpersonal relationships Weight bias is also present in close interpersonal relationships with friends, family and romantic partners. Research suggests obese and overweight women have a more difficult time finding partners and report less satisfying relationships when those relationships are established. Studies assessing personal ads have found that women who describe themselves as obese receive more negative evaluations by both men and women, and received fewer responses from men compared to ads in which women disclose having a history of drug abuse.44 Moreover, when college students (N ¼ 449) were asked to rank photographs of six potential sexual partners including one obese partner, one healthy partner and partners with various disabilities (e.g., missing a limb, diagnosed with a mental illness, history of sexually transmitted infections), consistently the obese partner was rated as least desirable.45 Overall, obese women are perceived as being less sexually attractive, skilled, or responsive compared to average weight peers.2,46 Among dating and married couples, heavier women had lower quality relationships that they predicted were significantly more likely to end. Family members are also frequent sources of interpersonal weight bias. Of particular concern, youth may even experience weight-related victimization from their parents and siblings.47 In a study of 4746 adolescents, 29% of girls and 16% of boys reported weight-related teasing from a family member.48 Such reports of weight stigmatization by family members continue through adulthood. A study of 2449 overweight and obese women found that 72% of participants rated family members as the most frequent source of weight stigma, often in the form of weight-based teasing, name calling and inappropriate comments. The majority of participants also named friends (60%) and spouses (47%) as perpetrators of weight bias.16 Perceptions of bias may place strain on close interpersonal relationships, especially for overweight women. Research has found that obese women are more dissatisfied with family and partner relationships,49 and have fewer close friends,50 compared to thin women.2 Further, negative weightrelated commentary from family members and significant others has been associated with disordered eating behaviors among male and female young adults.51 Although it is clear that obese persons face stigma within their social, romantic and familial relationships, further work is necessary to determine how weight bias differs by gender, ethnicity and BMI. Youth For youth who are overweight or obese, weight stigmatization translates into pervasive victimization, teasing, and bullying. These experiences may be explicit (e.g., verbal teasing, name calling,
R.M. Puhl, K.M. King / Best Practice & Research Clinical Endocrinology & Metabolism 27 (2013) 117–127
121
physical violence), or may take more subtle forms such as relational victimization (e.g., social exclusion, avoidance, being the subject of rumors). Self-report, prospective, and experimental studies have examined these experiences in overweight and obese youth (See review by Puhl & Latner, 2007), and show that weight bias and negative stereotypes are established early in childhood.5 Among children as young as age three, overweight peers are described as mean, ugly, stupid, lazy, and undesirable playmates,52 and by age four children can identify excess weight as the reason for their negative attitudes toward heavy peers.52 As children enter elementary school, stereotypes worsen, with students reporting that overweight peers are ugly, selfish, lazy, and stupid, and that they lie, get teased, and have few friends.53 Overweight and obese youth in elementary school face less peer acceptance, have fewer friends, and experience higher rates of bullying than thinner peers, even after accounting for gender, race, social skills, and grade level.33,54,55 In grades 3–6, the likelihood of being bullied is 63% higher for an obese child compared to a healthy weight peer.54 By middle school, bullying is more severe, frequent, and upsetting for overweight youth compared to non-overweight peers,56 and elicits more negative emotional reactions compared to being teased for other reasons.57 This appears especially apparent among girls and the heaviest youth.58 A study of 4746 middle and high school students found that 30% of girls and 24% of boys reported weight-based teasing from peers. For students at or above the 95th BMI percentile, rates of victimization increased to 63% of girls and 58% of boys.59 Similarly, a prospective study of 8210 youth documented that 36% of obese boys and 34% of obese girls reported being victims of weight-based teasing and various forms of bullying.60 Throughout adolescence, weight-based bullying remains widespread. In recent research examining victimization in adolescents aged 13–19 years (N ¼ 1555), students reported weight to be the most common reason that their peers were teased and bullied at school, which was more frequent than other reasons for bullying such as sexual orientation and race.61 This research additionally found that 92% of adolescents reported witnessing their overweight and obese peers being teased at school, 85% observed this occurring specifically during physical activities (e.g., gym glass), 67% observed them being excluded from social activities, 57% witnessed them being verbally threatened, and 54% saw them being physically harassed.61 Furthermore, the National Education Association (2011) surveyed 5056 teachers across the country regarding their perceptions of different forms of student bullying, and similarly found that weight-based bullying was viewed to be the most problematic form of bullying in the school setting.62 Taken together, the research documenting weight-based teasing and bullying toward overweight and obese youth is considerable, and indicates a clear need for intervention to identify youth most at risk and to implement measures to help protect them from pervasive teasing and torment. Consequences of weight stigmatization for adults Given the pervasiveness of societal weight bias, it is important to consider the consequences of being exposed to such stigmatization. Multiple adverse outcomes are associated with weight bias for overweight and obese individuals, affecting their psychological functioning and physical health. Psychological consequences Exposure to weight stigmatization contributes to a range of negative psychological outcomes, including poor body image, low self-esteem, social isolation and risk of depression and anxiety in both clinical and non-clinical samples of obese adults, see Ref.2 For example, frequency of weight stigmatization is positively associated with depression among treatment-seeking obese adults, even after controlling for effects of age, gender, BMI, and obesity onset.63 Previous experiences of appearancebased teasing are also associated with depression in adult women with Binge Eating Disorder (BED),64 and weight stigmatization has been found to contribute to depressed mood among obese adults seeking weight loss surgery, over and above variables such as BMI, gender, obesity onset, physical disability, and binge eating status.65 Similar findings have been demonstrated with respect to self-esteem and body dissatisfaction.63,66 Among non-clinical samples of adults, Carr and colleagues conducted a nationally representative study of 3354 American adults and found that reports of being mistreated due to weight were significantly associated with impaired mood.67 Another nationally representative study of over 9000 obese adults found that perceived weight discrimination was
122
R.M. Puhl, K.M. King / Best Practice & Research Clinical Endocrinology & Metabolism 27 (2013) 117–127
significantly associated with current diagnoses of mood disorders and substance abuse, as well as utilization of mental health services, after controlling for sociodemographic characteristics and perceived stress.68 Of importance, many of these studies suggest that weight stigmatization and mistreatment, rather than excess weight alone, increase risk for emotional distress. Consequences for eating behaviors and physical activity Weight bias may also reinforce unhealthy behaviors that contribute to obesity. Adults who report weight stigmatization engage in more frequent binge eating behaviors, are more likely to be diagnosed with BED, and are more likely to engage in maladaptive eating patterns and eating disorder symptoms.69 Psychological distress emerging from stigmatization may contribute to binge eating patterns, as those who internalize negative weight-based stigma are more vulnerable to binge eating.70 Stigmainduced psychological stress may also lead to maladaptive coping strategies that reinforce unhealthy eating behaviors. For example, in a study of 2449 overweight and obese women, 79% reported coping with weight stigma on multiple occasions by eating more food, and 75% reported coping by refusing to diet.16 Recent experimental research also demonstrated that overweight women who were exposed to weight stigmatizing stimuli consumed more than three times as many calories post-manipulation as overweight women who were exposed to neutral stimuli.71 In addition to maladaptive eating behaviors, research shows that adults who report experiences of weight stigmatization are more likely to avoid exercise, and have less motivation for exercise, even after controlling for BMI and body dissatisfaction.72 It may be that overweight individuals feel heightened vulnerability to negative attitudes and criticism in public settings where exercise occurs, and therefore make attempts to avoid potentially embarrassing or stigmatizing situations. These findings are important to highlight in face of commonly held perceptions that weight stigmatization may be helpful in providing incentive and motivation to obese individuals to lose weight or engage in healthier eating and exercise behaviors, see Refs.2,73 The existing research to date instead suggests that weight stigmatization is an unlikely motivator for weight loss, and may instead lead to unhealthy behaviors that reinforce obesity and impair weight loss efforts. Based on the present evidence, weight stigmatization seems to pose considerable harm for emotional wellbeing and health behaviors, and should not be considered an appropriate or effective tool to promote public health.73 Additional health consequences Weight bias may have additional links to physiological health outcomes. Although very little research has examined physiological effects of weight bias, some work found that adolescents who reported unfair treatment because of their physical appearance (including body weight) had elevated ambulatory blood pressure compared to those who did not report unfair treatment, even after accounting for typical determinants of blood pressure, including BMI.74 A recent study additionally demonstrated that experiences of weight-related stigma exacerbated the effects of waist-to-hip ratio on non-diabetic glycemic control,75 a risk factor for cardiovascular disease. Experiences with discrimination may also contribute to obesity itself, as some work has documented correlations between perceived interpersonal discrimination and abdominal adiposity.76 This area of research remains in its infancy but warrants additional research, given the potential for stigma to worsen health outcomes among individuals whose weight may already pose increased health risks. Experiencing weight bias may also have negative implications for health care utilization, and may play a contributing role in avoidance and delay of health care among obese individuals. For example, Amy and colleagues (2006) surveyed 498 overweight and obese women (with health insurance and high access to health care) about their perceived barriers to routine gynecological cancer screenings, and found that among the heaviest women, 68% reported delaying health care services because of their weight.77 Women attributed their decisions to delay medical care to disrespectful treatment and negative attitudes from providers because of their weight, embarrassment about being weighed by medical staff, and that gowns, exam tables, and other medical equipment were too small to be functional for their body size. The percentage of women who reported these bias-related barriers increased with BMI.77 More recent research with nationally representative samples of adults (N ¼ 1064) and
R.M. Puhl, K.M. King / Best Practice & Research Clinical Endocrinology & Metabolism 27 (2013) 117–127
123
parents (N ¼ 455) show that 19% of adults and 24% of parents would avoid future medical appointments if they felt a doctor had stigmatized them (or their child) because of their weight.78,79 Consequences of weight-based victimization in youth In light of the vulnerability of overweight and obese youth to pervasive weight-based teasing and bullying, it is important to examine the impact that these experiences have specifically for children and adolescents who are targeted. Thus far, the research to date indicates that weight-based victimization can hinder emotional, social, academic, and physical wellbeing. Similar to research with adults, evidence suggests that some of the consequences that youth experience from weight-based victimization may reinforce their excess weight and interfere with health behaviors. Emotional consequences Weight-based teasing may contribute to negative emotional consequences for overweight and obese children and adolescents.48 Among both clinical and non-clinical samples of obese youth, weight bias increases risk of depression, anxiety, low self-esteem, and body dissatisfaction. Importantly, these findings remain even after controlling for BMI and other variables like age, gender, and age of obesity onset,48,56,63 indicating that stigma, rather than body weight per se, leads to these negative emotional outcomes. For example, weight-based teasing, rather than actual body weight, has been found to be significantly related to poor body image among boys and girls.48,80 Moreover, a study of 4746 adolescents found that weight-based victimization was related to increased risk of depression, when in many cases weight status itself was not directly related.48,81 Perhaps the most severe emotional consequence of stigma among youth is their increased risk of suicidal behaviors. Obese adolescents exhibit more suicidal thoughts and attempts, with one study finding that obese girls were almost two times more likely to report a suicide attempt in the last year than average weight peers.82,83 Weight-based teasing is key in understanding this relationship; adolescents teased about their weight are 2–3 times more likely to report suicidal ideation. Moreover, one study found that over half of girls who experience weight-based victimization by peers and family consider committing suicide. Among boys, 13% who were teased by family members about their weight reported attempting suicide compared to 4% who were not teased.48 Social and academic consequences Weight-based teasing may also compromise adolescents’ abilities to form supportive social relationships with peers. Foundational research documented that overweight and obese elementary school students are liked less and experience higher levels of rejection than average weight students.84 More recent research using the National Longitudinal Study of Adolescent health (N ¼ 90,118) found that among adolescents aged 13–18, overweight adolescents were significantly more likely to experience social isolation and were less likely to be nominated as friends than lean students.85 Other work with adolescents (N ¼ 9943) found that obese girls and boys spent less time with friends and reported weaker social bonds than thinner peers, after controlling for variables such as grade level, race, and socio-economic status (SES).83 Consistently, overweight youth are cognizant that their weight status may impact their social relationships, with one study finding that 69% of overweight 9–11 year olds believed they would have more friends if they could lose weight.86 Positive social bonds are especially important for children and adolescents, and may impact academic performance. A study by Krukowski et al., 2009 (N ¼ 1071) found that when weight-based teasing was controlled for, overweight children no longer exhibited poorer school performance compared to their average weight peers.33 Weight-based teasing may also serve to disengage students from their school environments. A recent study found that adolescents reported that their grades were harmed and that they avoided going to school in response to experiences of weight-based teasing and
124
R.M. Puhl, K.M. King / Best Practice & Research Clinical Endocrinology & Metabolism 27 (2013) 117–127
bullying; the likelihood of students reporting these reactions increased by 5% per teasing incident, even after accounting for gender, race, age, grades, and weight status.87 Physical health consequences Physical health may also be impacted by weight stigma in direct and indirect ways. Overweight adolescents who experience frequent weight-based teasing are more likely to engage in disordered eating behaviors, such as binge eating, chronic dieting, vomiting and the unhealthy use of diet pills or laxatives, even when controlling for BMI.88 Similarly, prospective research has demonstrated that weight-based teasing predicted binge eating at 5 years of follow-up among both males and females, even after controlling for other factors.89 These findings suggest that weight-based teasing, rather than body weight alone, contributes to disordered eating. Weight-based victimization has also been associated with reduced physical activity and increased cardiovascular risk.58,90,91 For example, overweight youth who are victimized by their peers are less likely to participate in physical activity and physical education classes.92 Given recent research suggesting that overweight and obese youth are frequently teased in physical activities such as gym class,93 it is likely that youth avoid physical activity in order to escape victimization. Overweight and obese adolescent girls may also be at increased risk for frequent substance use, which has been documented as a coping strategy for stress associated with weight stigma.94 Ultimately, distress resulting from weight-based victimization may increase youth and adolescents’ risk for poor health outcomes such as hypertension and glucose intolerance.90,95 The recognition that bullying contributes to health consequences for obese children is a concern that parents are becoming increasingly aware of. Findings from a 2008 nationally representative household survey of 2064 individuals regarding parental health concerns found that parents with an overweight or obese child rated bullying as their top health concern for their child (from a list of 20 different health concerns).96 Conclusions The stigmatization, bullying, and discrimination of obese children and adults are pervasive and lead to damaging consequences for individuals who are targeted. Given that weight stigmatization has been consistently documented in major life domains such as employment, health care, and schools, millions of individuals are vulnerable. Research to date shows that weight stigmatization can increase vulnerability to a range of adverse outcomes for children and adults, including impaired psychological wellbeing, social isolation, academic consequences, economic inequalities, and unhealthy eating and exercise behaviors that can ultimately reinforce weight gain and impair weight loss efforts. Certainly more work is needed to better understand the impact of weight stigmatization on physiological health indices, but it is clear from existing research that quality of life is reduced for targets of weight stigma and discrimination. Thus, although the medical comorbidities of obesity require continued and immediate attention to improve the lives of obese persons, the adverse psychological, social, and health consequences resulting from weight stigmatization must also be prioritized in efforts to prevent and treat obesity.
Research agenda Increase longitudinal prospective studies to examine impact of weight bias over time Examine the extent to which weight stigma contributes to disparate educational outcomes Determine how weight bias within interpersonal relationships differs by gender, ethnicity and BMI Identify the nature/extent and impact of weight bias in public health campaigns Examine longitudinally whether/how weight stigma contributes to physiological health indices
R.M. Puhl, K.M. King / Best Practice & Research Clinical Endocrinology & Metabolism 27 (2013) 117–127
125
References 1. Puhl RM & Brownell KD. Bias, discrimination, and obesity. Obesity Research 2001; 9: 788–905. *2. Puhl R & Heuer CA. The stigma of obesity: a review and update. Obesity 2009; 17: 941–964. 3. Andreyeva T, Puhl RM & Brownell KD. Changes in perceived weight discrimination among Americans: 1995–1996 through 2004–2006. Obesity 2008; 16: 1129–1134. *4. Puhl RM, Andreyeva T & Brownell KD. Perceptions of weight discrimination: prevalence and comparison to race and gender discrimination in America. International Journal of Obesity 2008; 32: 992–1000. 5. Puhl RM & Latner JD. Stigma, obesity, and the health of the nation’s children. Psychological Bulletin 2007; 133: 557–580. *6. Rudolph CW, Wells CL, Weller MD et al. A meta-analysis of empirical studies of weight-based bias in the workplace. Journal of Vocational Behavior 2009; 74: 1–10. 7. Giel KE, Zipfel S, Alizadeh M et al. Stigmatization of obese individuals by human resource professionals: an experimental study. BMC Public Health 2012; 12: 525. 8. Sartore ML & Cunningham GB. Weight discrimination, hiring recommendations, person–job fit, and attributions: fitnessindustry implications. Journal of Sport Management 2007; 21: 172–193. 9. Roehling MV, Roehling PV & Odland LM. Investigating the validity of stereotypes about overweight employees: the relationship between body weight and normal personality traits. Group and Organization Management 2008; 33: 392–424. 10. Judge TA & Cable DM. When it comes to pay, do the thin win? The effect of weight on pay for men and women. Journal of Applied Psychology 2011; 96: 95–112. 11. Baum CL & Ford WF. The wage effects of obesity: a longitudinal study. Health Economics 2004; 13: 885–899. 12. Han E, Norton EC & Stearns SC. Weight and wages: fat versus lean paychecks. Health Economics 2008; 18: 535–548. 13. Han E, Norton EC & Powell LM. Direct and indirect effects of body weight on adult wages. Economics & Human Biology 2011; 9: 381–392. 14. Roehling MV, Roehling PV & Pichler S. The relationship between body weight and perceived weight-related employment discrimination: the role of sex and race. Journal of Vocational Behavior 2007; 71: 300–318. 15. Carr D & Friedman MA. Is obesity stigmatizing? Body weight, perceived discrimination, and psychological well-being in the United States. Journal of Health and Social Behavior 2005; 46: 244–259. 16. Puhl RM & Brownell KD. Confronting and coping with weight stigma: an investigation of overweight and obese adults. Obesity 2006; 14: 1802–1815. 17. Budd GM, Mariotti M, Graff D et al. Health care professionals’ attitudes about obesity: an integrative review. Applied Nursing Research 2011; 24: 127–137. 18. Foster GD, Wadden TA, Makris AP et al. Primary care physicians’ attitudes about obesity and its treatment. Obesity Research 2003; 11: 1168–1177. 19. Hebl MR & Xu J. Weighing the care: physicians’ reactions to the size of a patient. International Journal of Obesity 2001; 25: 1246–1252. *20. Huizinga MM, Cooper LA, Bleich SN et al. Physician respect for patients with obesity. Journal of General Internal Medicine 2009; 24: 1236–1239. *21. Sabin JA, Marini M & Nosek BA. Implicit and explicit anti-fat bias among a large sample of medical doctors by BMI, race/ ethnicity and gender. PLoS One 2012; 7: e48448. 22. Huizinga MM, Bleich SN, Beach MC et al. Disparity in physician perception of patients’ adherence to medications by obesity status. Obesity 2010; 18: 1932–1937. 23. Befort CA, Greiner KA, Hall S et al. Weight-related perceptions among patients and physicians: how well do physicians judge patients’ motivation to lose weight? Journal of General Internal Medicine 2006; 21: 1086–1090. 24. Mold F & Forbes A. Patients’ and professionals’ experiences and perspectives of obesity in health-care settings: a synthesis of current research. Health Expectations 2011; http://dx.doi.org/10.1111/j.1369-7625.2011.00699.x. 25. Thompson RL & Thomas DE. A cross-sectional survey of the opinions on weight loss treatments of adult obese patients attending a dietetic clinic. International Journal of Obesity 2000; 24: 164–170. 26. Hernandez-Boussard T, Ahmed SM & Morton JM. Obesity disparities in preventive care: findings from the National Ambulatory Medical Care Survey, 2005–2007. Obesity 2011; 20: 1639–1644. 27. Smith AW, Borowski LA, Liu B et al. US primary care physicians’ diet-, physical activity-, and weight-related care of adult patients. American Journal of Preventive Medicine 2011; 41: 33–42. 28. Post RE, Mainous AG, Gregorie SH et al. The influence of physician acknowledgment of patients’ weight status on patient perceptions of overweight and obesity in the United States. Archives of Internal Medicine 2011; 171: 316–321. 29. Neumark-Sztainer D, Story M & Harris T. Beliefs and attitudes about obesity among teachers and school health care providers working with adolescents. Journal of Nutrition Education 1999; 31: 3–9. 30. Greenleaf C & Weiller K. Perceptions of youth obesity among physical educators. Social Psychology of Education 2005; 8: 407–423. 31. Burmeister JM, Kiefner AE, Carels RA et al. Weight bias in graduate school admissions. Obesity 2012; http://dx.doi.org/10. 1002/oby.20171. 32. Bauer KW, Yang YW & Austin SB. “How can we stay healthy when you’re throwing all this in front of us?” Findings from focus groups and interviews in middle schools on environmental influences on nutrition and physical activity. Health Education & Behavior 2004; 31: 34–46. *33. Krukowski RA, West DS, Perez AP et al. Overweight children, weight-based teasing and academic performance. International Journal of Pediatric Obesity 2009; 4: 274–280. 34. Ata RN & Thompson JK. Weight bias in the media: a review of recent research. Obesity Facts 2010; 3: 41–46. *35. Himes SM & Thompson JK. Fat stigmatization in television shows and movies: a content analysis. Obesity 2007; 15: 712–718. 36. Klein H & Shiffman KS. Thin is “in” and stout is “out”: what animated cartoons tell viewers about body weight. Eating and Weight Disorders 2005; 10: 107–116. 37. Herbozo S, Tantleff-Dunn S, Gokee-Larose J et al. Beauty and thinness messages in children’s media: a content analysis. Eating Disorders 2004; 12: 21–34.
126
R.M. Puhl, K.M. King / Best Practice & Research Clinical Endocrinology & Metabolism 27 (2013) 117–127
38. BBC News: Obese blamed for the world’s ills. Retrieved July 25, 2008 from: http://news.bbc.co.uk/2/hi/health/7404268.stm. 39. Sawer P. Fat people blamed for global warming. Retrieved July 25, 2008 from: http://www.telegraph.co.uk/news/1973230/ Fat-people-blamed-for-global-warming.html. 40. Kolata G. Find yourself packing it on? Blame friends. Retrieved July 25, 2008 from: http://www.nytimes.com/2007/07/26/ health/26fat.html. 41. Boero N. All the news that’s fat to print: the American “obesity epidemic” and the media. Qualitative Sociology 2007; 30: 41–60. 42. Heuer C, McClure K & Puhl RM. Obesity stigma in online news: a visual content analysis. Journal of Health Communication 2011; 0: 1–12. 43. McClure K, Puhl RM & Heuer CA. Obesity in the news: do photographic images of obese persons influence anti-fat attitudes? Journal of Health Communication 2011; 16: 359–371. 44. Sitton S & Blanchard S. Men’s preferences in romantic partners: obesity vs. addiction. Psychological Reports 1995; 77. 45. Chen EY & Brown M. Obesity stigma in sexual relationships. Obesity Research 2005; 13: 1393–1397. 46. Regan PC. Sexual outcasts: the perceived impact of body weight and gender on sexuality. Journal of Applied Social Psychology 1996; 26: 1803–1815. 47. Keery H, Boutelle K, van den Berg P et al. The impact of appearance-related teasing by family members. Journal of Adolescent Health 2005; 37: 120–127. *48. Eisenberg ME, Neumark-Sztainer D & Story M. Associations of weight-based teasing and emotional well-being among adolescents. Archives of Pediatrics Adolescent Medicine 2003; 157: 733–738. 49. Ball K, Crawford D & Kenardy J. Longitudinal relationships among overweight, life satisfaction, and aspirations in young women. Obesity Research 2004; 12: 1019–1030. 50. Sarlio-Lahteenkorva S. Weight loss and quality of life among obese people. Social Indicators Research 2001; 54: 329–354. 51. Eisenberg ME, Berge JM, Fulkerson JA et al. Associations between hurtful weight-related comments by family and significant other and the development of disordered eating behaviors in young adults. Journal of Behavioral Medicine 2012; 35: 500–508. 52. Cramer P & Steinwert T. Thin is good, fat is bad: how early does it begin? Journal of Applied Developmental Psychology 1998; 19: 429–451. 53. Wardle J, Volz C & Golding C. Social variation in attitudes to obesity in children. International Journal of Obesity 1995; 19: 562–569. *54. Lumeng JC, Forrest P, Appugliese DP et al. Weight status as a predictor of being bullied in third through sixth grades. Pediatrics 2010; 125: e1301–e1307. 55. Zeller MH, Reiter-Purtill J & Ramey C. Negative peer perceptions of obese children in the classroom environment. Obesity 2008; 16: 755–762. 56. Hayden-Wade HA, Stein RI, Ghaderi A et al. Prevalence, characteristics, and correlates of teasing experiences among overweight children vs. non-overweight peers. Obesity Research 2005; 13(May): 1381–1392. 57. Carlson Jones D & Burrus Newman J. A three-factor model of teasing: the influence of friendship, gender, and topic on expected emotional reactions to teasing during early adolescence. Social Development 2005; 14: 421–439. 58. Faith MS, Leone MA, Ayers TS et al. Weight criticism during physical activity, coping skills, and reported physical activity in children. Pediatrics 2002; 110: e23–e31. 59. Neumark-Sztainer D, Falkner N, Story M et al. Weight-teasing among adolescents: correlations with weight status and disordered eating behaviors. International Journal of Obesity 2002; 26: 123–131. 60. Griffiths LJ, Wolke D, Page AS et al. Obesity and bullying: different effects for boys and girls. Archives of Disease in Childhood 2006; 91(September): 121–125. *61. Puhl RM, Luedicke J & Heuer C. Weight-based victimization toward overweight adolescents: observations and reactions of peers. Journal of School Health 2011; 81: 696–703. 62. Bradshaw CP, Waasdorp TE, O’Brennan LM et al. Findings from the National Education Association’s nationwide study of bullying: teachers’ and education support professionals’ perspectives 2011. 63. Friedman KE, Reichmann SK, Costanzo PR et al. Weight stigmatization and ideological beliefs: relation to psychological functioning in obese adults. Obesity Research 2005; 13: 907–916. 64. Jackson TD, Grilo CM & Masheb RM. Teasing history and eating disorder features: an age- and body mass index-matched comparison of bulimia nervosa and binge-eating disorder. Comprehensive Psychiatry 2002; 43: 108–113. 65. Chen EY, Bocchieri-Ricciardi LE, Munoz D et al. Depressed mood in class III obesity predicted by weight-related stigma. Obesity Surgery 2007; 17: 669–671. 66. Rosenberger PH, Henderson KE, Bell RL et al. Associations of weight-based teasing history and current eating disorder features and psychological functioning in bariatric surgery patients. Obesity Surgery 2007; 17: 470–477. 67. Carr D, Friedman MA & Jaffe K. Understanding the relationship between obesity and positive and negative affect: the role of psychosocial mechanisms. Body Image 2007; 4: 165–177. 68. Hatzenbuehler ML, Keyes KM & Hasin DS. Associations between perceived weight discrimination and the prevalence of psychiatric disorders in the general population. Obesity 2009; 17: 2033–2039. 69. Ashmore JA, Friedman KE, Reichmann SK et al. Weight-based stigmatization, psychological distress, & binge eating behavior among obese treatment-seeking adults. Eating Behaviors 2008; 9: 203–209. 70. Puhl RM, Moss-Racusin CA & Schwartz MB. Internalization of weight bias: implications for binge eating and emotional well-being. Obesity 2007; 15: 19–23. 71. Schvey N, Puhl RM & Brownell KD. The impact of weight stigma on caloric consumption. Obesity 2011; 19: 1957–1962. 72. Vartanian LR & Shaprow JG. Effects of weight stigma on exercise motivation and behavior: a preliminary investigation among college-aged females. Journal of Health Psychology 2008; 13: 131–138. 73. Puhl R, Peterson J & Luedicke J. Fighting obesity or obese persons? Public perceptions of obesity-related health messages. International Journal of Obesity 2012; http://dx.doi.org/10.1038/ijo.2012.156. 74. Matthews KA, Salomon K, Kenyon K et al. Unfair treatment, discrimination, and ambulatory blood pressure in black and white adolescents. Health Psychology 2005; 24: 258–265.
R.M. Puhl, K.M. King / Best Practice & Research Clinical Endocrinology & Metabolism 27 (2013) 117–127
127
75. Tsenkova VK, Carr D, Schoeller DA et al. Perceived weight discrimination amplifies the link between central adiposity and nondiabetic glycemic control (HbA1c). Annals of Behavioral Medicine 2011; 41: 243–251. 76. Lewis TT, Kravitz HM, Janssen I et al. Self-reported experiences of discrimination and visceral fat in middle-aged AfricanAmerican and Causcasian women. American Journal of Epidemiology. 2011; 173: 1223–1231. 77. Amy NK, Aalborg A, Lyons P et al. Barriers to routine gynecological cancer screening for White and African-American obese women. International Journal of Obesity 2006; 30: 147–155. 78. Puhl RM, Peterson JL & Luedicke J. Parental perceptions of weight terminology that providers use with youth. Pediatrics 2011; 128: e786–e793. 79. Puhl RM, Peterson JL & Luedicke J. Motivating or stigmatizing? Public perceptions of language about weight used by health providers. International Journal of Obesity 2011; http://dx.doi.org/10.1038/ijo.2012.110. 80. McCormack LA, Laska MN, Gray C et al. Weight-related teasing in a racially diverse sample of sixth-grade children. Journal of the American Dietetic Association 2011; 111: 431–436. 81. Quinlan NP, Hoy MB & Costanzo PR. Sticks and stones: the effects of teasing on psychosocial functioning in an overweight treatment-seeking sample. Social Development 2009; 18: 24. 82. Eaton DK, Lowry R, Brener ND et al. Associations of body mass index and perceived weight with suicide ideation and suicide attempts among US high school students. Archives of Pediatrics & Adolescent Medicine 2005; 159: 513–519. 83. Falkner NH, Neumark-Sztainer D, Story M et al. Social, educational, and psychological correlates of weight status in adolescents. Obesity Research 2001; 9: 33–42. 84. Strauss CC, Smith K, Frame C et al. Personal and interpersonal characteristics associated with childhood obesity. Journal of Pediatric Psychology 1985; 10: 337–343. 85. Strauss RS & Pollack HA. Social marginalization of overweight children. Archives of Pediatrics Adolescent Medicine 2003; 157: 746–752. 86. Pierce JW & Wardle J. Cause and effect beliefs and self-esteem of overweight children. Journal of Child Psychology and Psychiatry 1997; 38: 645–650. 87. Puhl RM & Luedicke J. Weight-based victimization among adolescents in the school setting: emotional reactions and coping behaviors. Journal of Youth and Adolescence 2012; 41: 27–40. 88. Libbey HP, Story MT, Neumark-Sztainer DR et al. Teasing, disordered eating behaviors, and psychological morbidities among overweight adolescents. Obesity 2008; 16: S24–S29. 89. Haines J, Neumark-Sztainer D, Eisenberg ME et al. Weight teasing and disordered eating behaviors in adolescents: longitudinal findings from Project EAT (Eating Among Teens). Pediatrics 2006; 117: 209–215. 90. Matthews KA, Salomon K, Brady SS et al. Cardiovascular reactivity to stress predicts future blood pressure in adolescence. Psychosomatic Medicine 2003; 65: 410–415. 91. Gray WN, Janicke DM, Ingerski LM et al. The impact of peer victimization, parent distress and child depression on barrier formation and physical activity in overweight youth. Journal of Developmental & Behavioral Pediatrics 2008; 29: 26–33. 92. Storch EA, Milsom VA, DeBraganza N et al. Peer victimization, psychosocial adjustment, and physical activity in overweight and at-risk-for-overweight youth. Journal of Pediatric Psychology 2007; 32: 80–89. 93. Peterson JL, Puhl RM & Luedicke J. An experimental assessment of physical educators’ expectations and attitudes: the importance of student weight and gender. Journal of School Health 2012; 82: 432–440. 94. Farhat T, Iannotti RJ & Simons-Morton BG. Overweight, obesity, youth, and health-risk behaviors. American Journal of Preventive Medicine 2010; 38: 258–267. 95. Goldbacher EM, Matthews KA & Salomon K. Central adiposity is associated with cardiovascular reactivity to stress in adolescents. Health Psychology 2005; 24: 375. 96. C.S. Mott Children’s Hospital. Bullying worries parents of overweight and obese children. C.S. Mott Children’s Hospital, the University of Michigan Department of Pediatrics and Communicable Diseases, and the University of Michigan Child Health and Evaluation Research (CHEAR) Unit, 2008.
Contents lists available at SciVerse ScienceDirect
Best Practice & Research Clinical Endocrinology & Metabolism journal homepage: www.elsevier.com/locate/beem
2
Weight discrimination and bullying Rebecca M. Puhl, PhD, Director of Research, Senior Research Scientist *, Kelly M. King, MPH, Research Associate Rudd Center for Food Policy and Obesity, Yale University, 309 Edwards Street, New Haven, CT 06511, USA
Keywords: obesity bias stigma social consequences victimization youth
Despite significant attention to the medical impacts of obesity, often ignored are the negative outcomes that obese children and adults experience as a result of stigma, bias, and discrimination. Obese individuals are frequently stigmatized because of their weight in many domains of daily life. Research spanning several decades has documented consistent weight bias and stigmatization in employment, health care, schools, the media, and interpersonal relationships. For overweight and obese youth, weight stigmatization translates into pervasive victimization, teasing, and bullying. Multiple adverse outcomes are associated with exposure to weight stigmatization, including depression, anxiety, low selfesteem, body dissatisfaction, suicidal ideation, poor academic performance, lower physical activity, maladaptive eating behaviors, and avoidance of health care. This review summarizes the nature and extent of weight stigmatization against overweight and obese individuals, as well as the resulting consequences that these experiences create for social, psychological, and physical health for children and adults who are targeted. Ó 2013 Elsevier Ltd. All rights reserved.
Introduction The health impacts of obesity have received significant attention by researchers, health professionals, and policy makers, leading to an increased recognition of the importance of focused prevention and treatment of obesity and its related comorbidities. However, often absent in the national discourse of obesity are the negative outcomes that obese children and adults experience as a result of bias, stigma, and discrimination. Overweight and obese persons are highly stigmatized in our society, and weight-based stereotypes remain widespread including perceptions that obese persons are lazy, unmotivated, incompetent, noncompliant, sloppy, lacking in self-discipline, and lacking in willpower.1,2 * Corresponding author. Tel.: þ1 203 432 7354; Fax: þ1 203 432 9674. E-mail address: [email protected] (R.M. Puhl). 1521-690X/$ – see front matter Ó 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.beem.2012.12.002
118
R.M. Puhl, K.M. King / Best Practice & Research Clinical Endocrinology & Metabolism 27 (2013) 117–127
The social acceptability of these stereotypes often lead to overt forms of prejudice and discrimination, including inequities in employment settings, disparities in health care, and disadvantages in education, see Ref.2 In the United States, the prevalence of weight discrimination has increased by 66% in the last decade,3 and is now comparable to and in some cases exceeds racial discrimination.4 Given the prevalence of overweight and obesity in the American population, the number of children and adults potentially faced with stigmatization is immense. The consequences of being denied jobs, disadvantaged in education, marginalized by health care professionals, or victimized by peers because of one’s weight can have a profound impact on quality of life, and may even lead to behaviors that reinforce obesity. This review summarizes the nature and extent of weight stigmatization against overweight and obese individuals, as well as the resulting consequences that these experiences create for social, psychological, and physical health for children and adults who are targeted. Documentation of weight stigmatization Although negative stigmatization toward overweight and obese persons has been documented in published research for over fifty years, this topic has only begun to receive focused attention in the obesity field in the last decade.1 Findings from population-based studies, experimental research, longitudinal and cross-sectional work all point to consistent stigma and discrimination against obese persons in multiple domains of living. The continued social acceptability of weight stigmatization leaves overweight and obese persons vulnerable to stigmatization in the workplace, health care settings, educational institutions, the media, and even in interpersonal relationships with their family members and friends.2 Of additional concern is the frequency and impact of bullying and victimization toward obese youth, who are especially vulnerable to the negative consequences of weight-based stigmatization.5 The evidence in each of these areas is summarized below. Employment Overweight and obese employees face frequent discrimination in the workplace. Considerable experimental research shows that compared to thinner employees with identical qualifications, overweight and obese employees face discriminatory hiring practices, are denied promotions, face wrongful termination, and are stigmatized by colleagues and supervisors because of their weight.6 Recent research by Giel and colleagues (2012) found that individuals in charge of hiring underestimated the occupational prestige of obese individuals and were more likely to disqualify them from being hired.7 In some cases, hiring managers report more willingness to hire a less qualified thinner candidate, than a more qualified overweight candidate.8 Disparate treatment likely stems from negative weight-based stereotypes such as beliefs that obese employees are less conscientious, agreeable, emotionally stable, and extraverted than normal-weight colleagues despite a lack of validity to these claims.9 Obese employees also receive lower wages than thinner individuals for the same work performed,10 with some research showing that obese women earn 6% less than healthy weight women, and obese men earn 3% less than thinner men.11 This obesity wage penalty has been documented across all race and gender groups, with the exception of African American men and women.12 It has been estimated that for women, every one unit increase in Body Mass Index (BMI) is associated with a 1.83% drop in hourly wages.13 Reports of employment discrimination among obese persons parallel the above findings. In a nationally representative sample of 2838 Americans, compared to non-overweight individuals, overweight persons were 12 times more likely to report employment discrimination; obese persons were 37 times more likely to report employment discrimination, and severely obese persons were 100 times more likely to report employment discrimination.14 Similar findings have been reported in other national samples15 and among obese women who report high levels of weight stigmatization from supervisors and co-workers.16 Health care Weight bias also extends to the health care setting, where overweight and obese patients are vulnerable to stigmatization from health providers. Studies have consistently documented that
R.M. Puhl, K.M. King / Best Practice & Research Clinical Endocrinology & Metabolism 27 (2013) 117–127
119
medical professionals (e.g., physicians, nurses, medical students, and other health professionals) hold negative stereotypes about overweight patients, see Ref.17 including perceptions that obese patients are lazy, noncompliant, undisciplined, and have low willpower.2 One study of over 620 primary care physicians found that over half of doctors ascribed traits like, awkward, unattractive, ugly and noncompliant to obese patients, while one-third categorized them as weak-willed, sloppy and lazy.18 Further, physicians exposed to patients with higher body mass index (BMI) reported having less respect for their patients, having less ability or desire to help their patients, and reported treating obesity was “more annoying” and a greater waste of their time.19,20 Such negative beliefs persist, even for health professionals who specialize in the treatment of obesity.21 Despite evidence that physicians hold perceptions that obese patients are noncompliant with medical advice, or lack the willpower to make lifestyle changes,22 recent research has challenged these assumptions and shows that patients’ reported levels of motivation for weight loss are significantly higher than physicians’ opinions.23 Ultimately, the mismatch between doctors’ perceptions and patients’ lived experiences may compromise the patient–provider relationship and hamper communication around healthy behavior change.24 Obese patients additionally report feeling disrespected, dismissed, and upset about comments made by heath providers because of their weight.25 In a selfreport study of 2449 overweight and obese women, 69% specifically reported being stigmatized about their weight from a doctor, and 52% reported this occurring multiple times. Thus, poor communication and perceived stigma in medical settings may impede access to preventative care for obese patients.26 Weight stigma may also partially explain why many physicians fail to counsel obese patients about their weight.27 Overweight and obese patients who do receive medical counseling, however, have more realistic perceptions of their weight, increased desire to lose weight and more recent attempts at weight loss, providing even further evidence as to why stigma reduction in the health care sector is crucial to the health of overweight and obese persons.28 Education Overweight and obese students experience weight stigmatization from peers and educators in educational settings.2 Negative weight-based stereotypes toward obese students have been increasingly reported by educators.29 Research demonstrates that teachers hold biased perceptions about overweight youths’ abilities, viewing them to have poorer social, reasoning, physical, and cooperation skills than nonoverweight students, as well lower expectations for overweight students across a range of performance areas.30 Such biases may limit the educational opportunities available for overweight students. A recent study by Burmeister et al., 2012 found that students with higher BMIs were significantly less likely than average weight peers to receive offers of admission to psychology graduate programs after completing the interview process, despite receiving more positive letters of recommendation overall.31 Obese students also report awareness of weight bias from educators,32 with previous work documenting that over a third of overweight and obese women (N ¼ 2449) reported experiencing weight stigmatization from a teacher or educator, with over 20% indicating that such experiences occurred on multiple occasions.16 Recent work has further demonstrated that experiences of weight-based teasing mediate the relationship between poor school performance and body mass index among school children.33 More work is needed in this area to determine the nature and extent to which weight stigma contributes to disparate educational outcomes among overweight students and their thinner peers. Media The social acceptability of weight stigma is readily apparent through the negative depiction of overweight and obese persons in television and film, see Ref.34 Within both child and adult entertainment, overweight individuals are more likely to be cast as minor characters, the targets of ridicule and humor, depicted engaging in stereotypical behaviors (e.g., eating or bingeing on unhealthy foods), and are less likely to be portrayed as having romantic partners or interactions with friends,35 while thin characters take on central roles and are assigned positive characteristics. Content analyses of male and female television characters have found that heavier women receive significantly more negative comments from male characters, while heavier male characters are more likely to make negative
120
R.M. Puhl, K.M. King / Best Practice & Research Clinical Endocrinology & Metabolism 27 (2013) 117–127
references about their own weight, with both types of commentary often reinforced with audience laughter. Similar findings exist in children’s media. A study of 1221 cartoons with over 4000 cartoon characters revealed that overweight characters were more likely to be portrayed as having socially undesirable traits compared to average weight or underweight characters who were portrayed positively.36 Specifically, overweight characters are often portrayed as more aggressive, anti-social, evil, unattractive, unfriendly, disliked by others, and eating food compared to thinner characters who are depicted as being sociable, kind, successful, popular, attractive, and happy.37 Obese individuals are also negatively stereotyped in news media, and have been implicated in national stories as being responsible for increasing fuel prices,38 global warming39 and social contagion of obesity.2,40 Research has documented that the news media often frames obesity as an issue of personal responsibility, prioritizing overeating and lack of exercise as key explanations, over genetic, environmental or socioeconomic factors that may contribute to overweight. An analysis of 751 obesity related articles published in the New York Times between 1990 and 2001 revealed that the majority of news stories blame individuals for obesity and resulting moral panic. Similar to entertainment media, overweight people in news media were characterized by negative traits such as “stupid,” “ugly,” “naïve,” “irresponsible,” “lazy”, “greedy,” “without manners,” and “repugnant.”41 Moreover, a recent content analysis of online news imagery revealed that 72% of images portrayed overweight and obese individuals in a stigmatizing manner.42 Individuals who view negative photographs in news media display more negative attitudes toward obese people,43 suggesting that using more positive media portrayals of obese persons that challenge common stereotypes may help reduce negative societal stigma. Interpersonal relationships Weight bias is also present in close interpersonal relationships with friends, family and romantic partners. Research suggests obese and overweight women have a more difficult time finding partners and report less satisfying relationships when those relationships are established. Studies assessing personal ads have found that women who describe themselves as obese receive more negative evaluations by both men and women, and received fewer responses from men compared to ads in which women disclose having a history of drug abuse.44 Moreover, when college students (N ¼ 449) were asked to rank photographs of six potential sexual partners including one obese partner, one healthy partner and partners with various disabilities (e.g., missing a limb, diagnosed with a mental illness, history of sexually transmitted infections), consistently the obese partner was rated as least desirable.45 Overall, obese women are perceived as being less sexually attractive, skilled, or responsive compared to average weight peers.2,46 Among dating and married couples, heavier women had lower quality relationships that they predicted were significantly more likely to end. Family members are also frequent sources of interpersonal weight bias. Of particular concern, youth may even experience weight-related victimization from their parents and siblings.47 In a study of 4746 adolescents, 29% of girls and 16% of boys reported weight-related teasing from a family member.48 Such reports of weight stigmatization by family members continue through adulthood. A study of 2449 overweight and obese women found that 72% of participants rated family members as the most frequent source of weight stigma, often in the form of weight-based teasing, name calling and inappropriate comments. The majority of participants also named friends (60%) and spouses (47%) as perpetrators of weight bias.16 Perceptions of bias may place strain on close interpersonal relationships, especially for overweight women. Research has found that obese women are more dissatisfied with family and partner relationships,49 and have fewer close friends,50 compared to thin women.2 Further, negative weightrelated commentary from family members and significant others has been associated with disordered eating behaviors among male and female young adults.51 Although it is clear that obese persons face stigma within their social, romantic and familial relationships, further work is necessary to determine how weight bias differs by gender, ethnicity and BMI. Youth For youth who are overweight or obese, weight stigmatization translates into pervasive victimization, teasing, and bullying. These experiences may be explicit (e.g., verbal teasing, name calling,
R.M. Puhl, K.M. King / Best Practice & Research Clinical Endocrinology & Metabolism 27 (2013) 117–127
121
physical violence), or may take more subtle forms such as relational victimization (e.g., social exclusion, avoidance, being the subject of rumors). Self-report, prospective, and experimental studies have examined these experiences in overweight and obese youth (See review by Puhl & Latner, 2007), and show that weight bias and negative stereotypes are established early in childhood.5 Among children as young as age three, overweight peers are described as mean, ugly, stupid, lazy, and undesirable playmates,52 and by age four children can identify excess weight as the reason for their negative attitudes toward heavy peers.52 As children enter elementary school, stereotypes worsen, with students reporting that overweight peers are ugly, selfish, lazy, and stupid, and that they lie, get teased, and have few friends.53 Overweight and obese youth in elementary school face less peer acceptance, have fewer friends, and experience higher rates of bullying than thinner peers, even after accounting for gender, race, social skills, and grade level.33,54,55 In grades 3–6, the likelihood of being bullied is 63% higher for an obese child compared to a healthy weight peer.54 By middle school, bullying is more severe, frequent, and upsetting for overweight youth compared to non-overweight peers,56 and elicits more negative emotional reactions compared to being teased for other reasons.57 This appears especially apparent among girls and the heaviest youth.58 A study of 4746 middle and high school students found that 30% of girls and 24% of boys reported weight-based teasing from peers. For students at or above the 95th BMI percentile, rates of victimization increased to 63% of girls and 58% of boys.59 Similarly, a prospective study of 8210 youth documented that 36% of obese boys and 34% of obese girls reported being victims of weight-based teasing and various forms of bullying.60 Throughout adolescence, weight-based bullying remains widespread. In recent research examining victimization in adolescents aged 13–19 years (N ¼ 1555), students reported weight to be the most common reason that their peers were teased and bullied at school, which was more frequent than other reasons for bullying such as sexual orientation and race.61 This research additionally found that 92% of adolescents reported witnessing their overweight and obese peers being teased at school, 85% observed this occurring specifically during physical activities (e.g., gym glass), 67% observed them being excluded from social activities, 57% witnessed them being verbally threatened, and 54% saw them being physically harassed.61 Furthermore, the National Education Association (2011) surveyed 5056 teachers across the country regarding their perceptions of different forms of student bullying, and similarly found that weight-based bullying was viewed to be the most problematic form of bullying in the school setting.62 Taken together, the research documenting weight-based teasing and bullying toward overweight and obese youth is considerable, and indicates a clear need for intervention to identify youth most at risk and to implement measures to help protect them from pervasive teasing and torment. Consequences of weight stigmatization for adults Given the pervasiveness of societal weight bias, it is important to consider the consequences of being exposed to such stigmatization. Multiple adverse outcomes are associated with weight bias for overweight and obese individuals, affecting their psychological functioning and physical health. Psychological consequences Exposure to weight stigmatization contributes to a range of negative psychological outcomes, including poor body image, low self-esteem, social isolation and risk of depression and anxiety in both clinical and non-clinical samples of obese adults, see Ref.2 For example, frequency of weight stigmatization is positively associated with depression among treatment-seeking obese adults, even after controlling for effects of age, gender, BMI, and obesity onset.63 Previous experiences of appearancebased teasing are also associated with depression in adult women with Binge Eating Disorder (BED),64 and weight stigmatization has been found to contribute to depressed mood among obese adults seeking weight loss surgery, over and above variables such as BMI, gender, obesity onset, physical disability, and binge eating status.65 Similar findings have been demonstrated with respect to self-esteem and body dissatisfaction.63,66 Among non-clinical samples of adults, Carr and colleagues conducted a nationally representative study of 3354 American adults and found that reports of being mistreated due to weight were significantly associated with impaired mood.67 Another nationally representative study of over 9000 obese adults found that perceived weight discrimination was
122
R.M. Puhl, K.M. King / Best Practice & Research Clinical Endocrinology & Metabolism 27 (2013) 117–127
significantly associated with current diagnoses of mood disorders and substance abuse, as well as utilization of mental health services, after controlling for sociodemographic characteristics and perceived stress.68 Of importance, many of these studies suggest that weight stigmatization and mistreatment, rather than excess weight alone, increase risk for emotional distress. Consequences for eating behaviors and physical activity Weight bias may also reinforce unhealthy behaviors that contribute to obesity. Adults who report weight stigmatization engage in more frequent binge eating behaviors, are more likely to be diagnosed with BED, and are more likely to engage in maladaptive eating patterns and eating disorder symptoms.69 Psychological distress emerging from stigmatization may contribute to binge eating patterns, as those who internalize negative weight-based stigma are more vulnerable to binge eating.70 Stigmainduced psychological stress may also lead to maladaptive coping strategies that reinforce unhealthy eating behaviors. For example, in a study of 2449 overweight and obese women, 79% reported coping with weight stigma on multiple occasions by eating more food, and 75% reported coping by refusing to diet.16 Recent experimental research also demonstrated that overweight women who were exposed to weight stigmatizing stimuli consumed more than three times as many calories post-manipulation as overweight women who were exposed to neutral stimuli.71 In addition to maladaptive eating behaviors, research shows that adults who report experiences of weight stigmatization are more likely to avoid exercise, and have less motivation for exercise, even after controlling for BMI and body dissatisfaction.72 It may be that overweight individuals feel heightened vulnerability to negative attitudes and criticism in public settings where exercise occurs, and therefore make attempts to avoid potentially embarrassing or stigmatizing situations. These findings are important to highlight in face of commonly held perceptions that weight stigmatization may be helpful in providing incentive and motivation to obese individuals to lose weight or engage in healthier eating and exercise behaviors, see Refs.2,73 The existing research to date instead suggests that weight stigmatization is an unlikely motivator for weight loss, and may instead lead to unhealthy behaviors that reinforce obesity and impair weight loss efforts. Based on the present evidence, weight stigmatization seems to pose considerable harm for emotional wellbeing and health behaviors, and should not be considered an appropriate or effective tool to promote public health.73 Additional health consequences Weight bias may have additional links to physiological health outcomes. Although very little research has examined physiological effects of weight bias, some work found that adolescents who reported unfair treatment because of their physical appearance (including body weight) had elevated ambulatory blood pressure compared to those who did not report unfair treatment, even after accounting for typical determinants of blood pressure, including BMI.74 A recent study additionally demonstrated that experiences of weight-related stigma exacerbated the effects of waist-to-hip ratio on non-diabetic glycemic control,75 a risk factor for cardiovascular disease. Experiences with discrimination may also contribute to obesity itself, as some work has documented correlations between perceived interpersonal discrimination and abdominal adiposity.76 This area of research remains in its infancy but warrants additional research, given the potential for stigma to worsen health outcomes among individuals whose weight may already pose increased health risks. Experiencing weight bias may also have negative implications for health care utilization, and may play a contributing role in avoidance and delay of health care among obese individuals. For example, Amy and colleagues (2006) surveyed 498 overweight and obese women (with health insurance and high access to health care) about their perceived barriers to routine gynecological cancer screenings, and found that among the heaviest women, 68% reported delaying health care services because of their weight.77 Women attributed their decisions to delay medical care to disrespectful treatment and negative attitudes from providers because of their weight, embarrassment about being weighed by medical staff, and that gowns, exam tables, and other medical equipment were too small to be functional for their body size. The percentage of women who reported these bias-related barriers increased with BMI.77 More recent research with nationally representative samples of adults (N ¼ 1064) and
R.M. Puhl, K.M. King / Best Practice & Research Clinical Endocrinology & Metabolism 27 (2013) 117–127
123
parents (N ¼ 455) show that 19% of adults and 24% of parents would avoid future medical appointments if they felt a doctor had stigmatized them (or their child) because of their weight.78,79 Consequences of weight-based victimization in youth In light of the vulnerability of overweight and obese youth to pervasive weight-based teasing and bullying, it is important to examine the impact that these experiences have specifically for children and adolescents who are targeted. Thus far, the research to date indicates that weight-based victimization can hinder emotional, social, academic, and physical wellbeing. Similar to research with adults, evidence suggests that some of the consequences that youth experience from weight-based victimization may reinforce their excess weight and interfere with health behaviors. Emotional consequences Weight-based teasing may contribute to negative emotional consequences for overweight and obese children and adolescents.48 Among both clinical and non-clinical samples of obese youth, weight bias increases risk of depression, anxiety, low self-esteem, and body dissatisfaction. Importantly, these findings remain even after controlling for BMI and other variables like age, gender, and age of obesity onset,48,56,63 indicating that stigma, rather than body weight per se, leads to these negative emotional outcomes. For example, weight-based teasing, rather than actual body weight, has been found to be significantly related to poor body image among boys and girls.48,80 Moreover, a study of 4746 adolescents found that weight-based victimization was related to increased risk of depression, when in many cases weight status itself was not directly related.48,81 Perhaps the most severe emotional consequence of stigma among youth is their increased risk of suicidal behaviors. Obese adolescents exhibit more suicidal thoughts and attempts, with one study finding that obese girls were almost two times more likely to report a suicide attempt in the last year than average weight peers.82,83 Weight-based teasing is key in understanding this relationship; adolescents teased about their weight are 2–3 times more likely to report suicidal ideation. Moreover, one study found that over half of girls who experience weight-based victimization by peers and family consider committing suicide. Among boys, 13% who were teased by family members about their weight reported attempting suicide compared to 4% who were not teased.48 Social and academic consequences Weight-based teasing may also compromise adolescents’ abilities to form supportive social relationships with peers. Foundational research documented that overweight and obese elementary school students are liked less and experience higher levels of rejection than average weight students.84 More recent research using the National Longitudinal Study of Adolescent health (N ¼ 90,118) found that among adolescents aged 13–18, overweight adolescents were significantly more likely to experience social isolation and were less likely to be nominated as friends than lean students.85 Other work with adolescents (N ¼ 9943) found that obese girls and boys spent less time with friends and reported weaker social bonds than thinner peers, after controlling for variables such as grade level, race, and socio-economic status (SES).83 Consistently, overweight youth are cognizant that their weight status may impact their social relationships, with one study finding that 69% of overweight 9–11 year olds believed they would have more friends if they could lose weight.86 Positive social bonds are especially important for children and adolescents, and may impact academic performance. A study by Krukowski et al., 2009 (N ¼ 1071) found that when weight-based teasing was controlled for, overweight children no longer exhibited poorer school performance compared to their average weight peers.33 Weight-based teasing may also serve to disengage students from their school environments. A recent study found that adolescents reported that their grades were harmed and that they avoided going to school in response to experiences of weight-based teasing and
124
R.M. Puhl, K.M. King / Best Practice & Research Clinical Endocrinology & Metabolism 27 (2013) 117–127
bullying; the likelihood of students reporting these reactions increased by 5% per teasing incident, even after accounting for gender, race, age, grades, and weight status.87 Physical health consequences Physical health may also be impacted by weight stigma in direct and indirect ways. Overweight adolescents who experience frequent weight-based teasing are more likely to engage in disordered eating behaviors, such as binge eating, chronic dieting, vomiting and the unhealthy use of diet pills or laxatives, even when controlling for BMI.88 Similarly, prospective research has demonstrated that weight-based teasing predicted binge eating at 5 years of follow-up among both males and females, even after controlling for other factors.89 These findings suggest that weight-based teasing, rather than body weight alone, contributes to disordered eating. Weight-based victimization has also been associated with reduced physical activity and increased cardiovascular risk.58,90,91 For example, overweight youth who are victimized by their peers are less likely to participate in physical activity and physical education classes.92 Given recent research suggesting that overweight and obese youth are frequently teased in physical activities such as gym class,93 it is likely that youth avoid physical activity in order to escape victimization. Overweight and obese adolescent girls may also be at increased risk for frequent substance use, which has been documented as a coping strategy for stress associated with weight stigma.94 Ultimately, distress resulting from weight-based victimization may increase youth and adolescents’ risk for poor health outcomes such as hypertension and glucose intolerance.90,95 The recognition that bullying contributes to health consequences for obese children is a concern that parents are becoming increasingly aware of. Findings from a 2008 nationally representative household survey of 2064 individuals regarding parental health concerns found that parents with an overweight or obese child rated bullying as their top health concern for their child (from a list of 20 different health concerns).96 Conclusions The stigmatization, bullying, and discrimination of obese children and adults are pervasive and lead to damaging consequences for individuals who are targeted. Given that weight stigmatization has been consistently documented in major life domains such as employment, health care, and schools, millions of individuals are vulnerable. Research to date shows that weight stigmatization can increase vulnerability to a range of adverse outcomes for children and adults, including impaired psychological wellbeing, social isolation, academic consequences, economic inequalities, and unhealthy eating and exercise behaviors that can ultimately reinforce weight gain and impair weight loss efforts. Certainly more work is needed to better understand the impact of weight stigmatization on physiological health indices, but it is clear from existing research that quality of life is reduced for targets of weight stigma and discrimination. Thus, although the medical comorbidities of obesity require continued and immediate attention to improve the lives of obese persons, the adverse psychological, social, and health consequences resulting from weight stigmatization must also be prioritized in efforts to prevent and treat obesity.
Research agenda Increase longitudinal prospective studies to examine impact of weight bias over time Examine the extent to which weight stigma contributes to disparate educational outcomes Determine how weight bias within interpersonal relationships differs by gender, ethnicity and BMI Identify the nature/extent and impact of weight bias in public health campaigns Examine longitudinally whether/how weight stigma contributes to physiological health indices
R.M. Puhl, K.M. King / Best Practice & Research Clinical Endocrinology & Metabolism 27 (2013) 117–127
125
References 1. Puhl RM & Brownell KD. Bias, discrimination, and obesity. Obesity Research 2001; 9: 788–905. *2. Puhl R & Heuer CA. The stigma of obesity: a review and update. Obesity 2009; 17: 941–964. 3. Andreyeva T, Puhl RM & Brownell KD. Changes in perceived weight discrimination among Americans: 1995–1996 through 2004–2006. Obesity 2008; 16: 1129–1134. *4. Puhl RM, Andreyeva T & Brownell KD. Perceptions of weight discrimination: prevalence and comparison to race and gender discrimination in America. International Journal of Obesity 2008; 32: 992–1000. 5. Puhl RM & Latner JD. Stigma, obesity, and the health of the nation’s children. Psychological Bulletin 2007; 133: 557–580. *6. Rudolph CW, Wells CL, Weller MD et al. A meta-analysis of empirical studies of weight-based bias in the workplace. Journal of Vocational Behavior 2009; 74: 1–10. 7. Giel KE, Zipfel S, Alizadeh M et al. Stigmatization of obese individuals by human resource professionals: an experimental study. BMC Public Health 2012; 12: 525. 8. Sartore ML & Cunningham GB. Weight discrimination, hiring recommendations, person–job fit, and attributions: fitnessindustry implications. Journal of Sport Management 2007; 21: 172–193. 9. Roehling MV, Roehling PV & Odland LM. Investigating the validity of stereotypes about overweight employees: the relationship between body weight and normal personality traits. Group and Organization Management 2008; 33: 392–424. 10. Judge TA & Cable DM. When it comes to pay, do the thin win? The effect of weight on pay for men and women. Journal of Applied Psychology 2011; 96: 95–112. 11. Baum CL & Ford WF. The wage effects of obesity: a longitudinal study. Health Economics 2004; 13: 885–899. 12. Han E, Norton EC & Stearns SC. Weight and wages: fat versus lean paychecks. Health Economics 2008; 18: 535–548. 13. Han E, Norton EC & Powell LM. Direct and indirect effects of body weight on adult wages. Economics & Human Biology 2011; 9: 381–392. 14. Roehling MV, Roehling PV & Pichler S. The relationship between body weight and perceived weight-related employment discrimination: the role of sex and race. Journal of Vocational Behavior 2007; 71: 300–318. 15. Carr D & Friedman MA. Is obesity stigmatizing? Body weight, perceived discrimination, and psychological well-being in the United States. Journal of Health and Social Behavior 2005; 46: 244–259. 16. Puhl RM & Brownell KD. Confronting and coping with weight stigma: an investigation of overweight and obese adults. Obesity 2006; 14: 1802–1815. 17. Budd GM, Mariotti M, Graff D et al. Health care professionals’ attitudes about obesity: an integrative review. Applied Nursing Research 2011; 24: 127–137. 18. Foster GD, Wadden TA, Makris AP et al. Primary care physicians’ attitudes about obesity and its treatment. Obesity Research 2003; 11: 1168–1177. 19. Hebl MR & Xu J. Weighing the care: physicians’ reactions to the size of a patient. International Journal of Obesity 2001; 25: 1246–1252. *20. Huizinga MM, Cooper LA, Bleich SN et al. Physician respect for patients with obesity. Journal of General Internal Medicine 2009; 24: 1236–1239. *21. Sabin JA, Marini M & Nosek BA. Implicit and explicit anti-fat bias among a large sample of medical doctors by BMI, race/ ethnicity and gender. PLoS One 2012; 7: e48448. 22. Huizinga MM, Bleich SN, Beach MC et al. Disparity in physician perception of patients’ adherence to medications by obesity status. Obesity 2010; 18: 1932–1937. 23. Befort CA, Greiner KA, Hall S et al. Weight-related perceptions among patients and physicians: how well do physicians judge patients’ motivation to lose weight? Journal of General Internal Medicine 2006; 21: 1086–1090. 24. Mold F & Forbes A. Patients’ and professionals’ experiences and perspectives of obesity in health-care settings: a synthesis of current research. Health Expectations 2011; http://dx.doi.org/10.1111/j.1369-7625.2011.00699.x. 25. Thompson RL & Thomas DE. A cross-sectional survey of the opinions on weight loss treatments of adult obese patients attending a dietetic clinic. International Journal of Obesity 2000; 24: 164–170. 26. Hernandez-Boussard T, Ahmed SM & Morton JM. Obesity disparities in preventive care: findings from the National Ambulatory Medical Care Survey, 2005–2007. Obesity 2011; 20: 1639–1644. 27. Smith AW, Borowski LA, Liu B et al. US primary care physicians’ diet-, physical activity-, and weight-related care of adult patients. American Journal of Preventive Medicine 2011; 41: 33–42. 28. Post RE, Mainous AG, Gregorie SH et al. The influence of physician acknowledgment of patients’ weight status on patient perceptions of overweight and obesity in the United States. Archives of Internal Medicine 2011; 171: 316–321. 29. Neumark-Sztainer D, Story M & Harris T. Beliefs and attitudes about obesity among teachers and school health care providers working with adolescents. Journal of Nutrition Education 1999; 31: 3–9. 30. Greenleaf C & Weiller K. Perceptions of youth obesity among physical educators. Social Psychology of Education 2005; 8: 407–423. 31. Burmeister JM, Kiefner AE, Carels RA et al. Weight bias in graduate school admissions. Obesity 2012; http://dx.doi.org/10. 1002/oby.20171. 32. Bauer KW, Yang YW & Austin SB. “How can we stay healthy when you’re throwing all this in front of us?” Findings from focus groups and interviews in middle schools on environmental influences on nutrition and physical activity. Health Education & Behavior 2004; 31: 34–46. *33. Krukowski RA, West DS, Perez AP et al. Overweight children, weight-based teasing and academic performance. International Journal of Pediatric Obesity 2009; 4: 274–280. 34. Ata RN & Thompson JK. Weight bias in the media: a review of recent research. Obesity Facts 2010; 3: 41–46. *35. Himes SM & Thompson JK. Fat stigmatization in television shows and movies: a content analysis. Obesity 2007; 15: 712–718. 36. Klein H & Shiffman KS. Thin is “in” and stout is “out”: what animated cartoons tell viewers about body weight. Eating and Weight Disorders 2005; 10: 107–116. 37. Herbozo S, Tantleff-Dunn S, Gokee-Larose J et al. Beauty and thinness messages in children’s media: a content analysis. Eating Disorders 2004; 12: 21–34.
126
R.M. Puhl, K.M. King / Best Practice & Research Clinical Endocrinology & Metabolism 27 (2013) 117–127
38. BBC News: Obese blamed for the world’s ills. Retrieved July 25, 2008 from: http://news.bbc.co.uk/2/hi/health/7404268.stm. 39. Sawer P. Fat people blamed for global warming. Retrieved July 25, 2008 from: http://www.telegraph.co.uk/news/1973230/ Fat-people-blamed-for-global-warming.html. 40. Kolata G. Find yourself packing it on? Blame friends. Retrieved July 25, 2008 from: http://www.nytimes.com/2007/07/26/ health/26fat.html. 41. Boero N. All the news that’s fat to print: the American “obesity epidemic” and the media. Qualitative Sociology 2007; 30: 41–60. 42. Heuer C, McClure K & Puhl RM. Obesity stigma in online news: a visual content analysis. Journal of Health Communication 2011; 0: 1–12. 43. McClure K, Puhl RM & Heuer CA. Obesity in the news: do photographic images of obese persons influence anti-fat attitudes? Journal of Health Communication 2011; 16: 359–371. 44. Sitton S & Blanchard S. Men’s preferences in romantic partners: obesity vs. addiction. Psychological Reports 1995; 77. 45. Chen EY & Brown M. Obesity stigma in sexual relationships. Obesity Research 2005; 13: 1393–1397. 46. Regan PC. Sexual outcasts: the perceived impact of body weight and gender on sexuality. Journal of Applied Social Psychology 1996; 26: 1803–1815. 47. Keery H, Boutelle K, van den Berg P et al. The impact of appearance-related teasing by family members. Journal of Adolescent Health 2005; 37: 120–127. *48. Eisenberg ME, Neumark-Sztainer D & Story M. Associations of weight-based teasing and emotional well-being among adolescents. Archives of Pediatrics Adolescent Medicine 2003; 157: 733–738. 49. Ball K, Crawford D & Kenardy J. Longitudinal relationships among overweight, life satisfaction, and aspirations in young women. Obesity Research 2004; 12: 1019–1030. 50. Sarlio-Lahteenkorva S. Weight loss and quality of life among obese people. Social Indicators Research 2001; 54: 329–354. 51. Eisenberg ME, Berge JM, Fulkerson JA et al. Associations between hurtful weight-related comments by family and significant other and the development of disordered eating behaviors in young adults. Journal of Behavioral Medicine 2012; 35: 500–508. 52. Cramer P & Steinwert T. Thin is good, fat is bad: how early does it begin? Journal of Applied Developmental Psychology 1998; 19: 429–451. 53. Wardle J, Volz C & Golding C. Social variation in attitudes to obesity in children. International Journal of Obesity 1995; 19: 562–569. *54. Lumeng JC, Forrest P, Appugliese DP et al. Weight status as a predictor of being bullied in third through sixth grades. Pediatrics 2010; 125: e1301–e1307. 55. Zeller MH, Reiter-Purtill J & Ramey C. Negative peer perceptions of obese children in the classroom environment. Obesity 2008; 16: 755–762. 56. Hayden-Wade HA, Stein RI, Ghaderi A et al. Prevalence, characteristics, and correlates of teasing experiences among overweight children vs. non-overweight peers. Obesity Research 2005; 13(May): 1381–1392. 57. Carlson Jones D & Burrus Newman J. A three-factor model of teasing: the influence of friendship, gender, and topic on expected emotional reactions to teasing during early adolescence. Social Development 2005; 14: 421–439. 58. Faith MS, Leone MA, Ayers TS et al. Weight criticism during physical activity, coping skills, and reported physical activity in children. Pediatrics 2002; 110: e23–e31. 59. Neumark-Sztainer D, Falkner N, Story M et al. Weight-teasing among adolescents: correlations with weight status and disordered eating behaviors. International Journal of Obesity 2002; 26: 123–131. 60. Griffiths LJ, Wolke D, Page AS et al. Obesity and bullying: different effects for boys and girls. Archives of Disease in Childhood 2006; 91(September): 121–125. *61. Puhl RM, Luedicke J & Heuer C. Weight-based victimization toward overweight adolescents: observations and reactions of peers. Journal of School Health 2011; 81: 696–703. 62. Bradshaw CP, Waasdorp TE, O’Brennan LM et al. Findings from the National Education Association’s nationwide study of bullying: teachers’ and education support professionals’ perspectives 2011. 63. Friedman KE, Reichmann SK, Costanzo PR et al. Weight stigmatization and ideological beliefs: relation to psychological functioning in obese adults. Obesity Research 2005; 13: 907–916. 64. Jackson TD, Grilo CM & Masheb RM. Teasing history and eating disorder features: an age- and body mass index-matched comparison of bulimia nervosa and binge-eating disorder. Comprehensive Psychiatry 2002; 43: 108–113. 65. Chen EY, Bocchieri-Ricciardi LE, Munoz D et al. Depressed mood in class III obesity predicted by weight-related stigma. Obesity Surgery 2007; 17: 669–671. 66. Rosenberger PH, Henderson KE, Bell RL et al. Associations of weight-based teasing history and current eating disorder features and psychological functioning in bariatric surgery patients. Obesity Surgery 2007; 17: 470–477. 67. Carr D, Friedman MA & Jaffe K. Understanding the relationship between obesity and positive and negative affect: the role of psychosocial mechanisms. Body Image 2007; 4: 165–177. 68. Hatzenbuehler ML, Keyes KM & Hasin DS. Associations between perceived weight discrimination and the prevalence of psychiatric disorders in the general population. Obesity 2009; 17: 2033–2039. 69. Ashmore JA, Friedman KE, Reichmann SK et al. Weight-based stigmatization, psychological distress, & binge eating behavior among obese treatment-seeking adults. Eating Behaviors 2008; 9: 203–209. 70. Puhl RM, Moss-Racusin CA & Schwartz MB. Internalization of weight bias: implications for binge eating and emotional well-being. Obesity 2007; 15: 19–23. 71. Schvey N, Puhl RM & Brownell KD. The impact of weight stigma on caloric consumption. Obesity 2011; 19: 1957–1962. 72. Vartanian LR & Shaprow JG. Effects of weight stigma on exercise motivation and behavior: a preliminary investigation among college-aged females. Journal of Health Psychology 2008; 13: 131–138. 73. Puhl R, Peterson J & Luedicke J. Fighting obesity or obese persons? Public perceptions of obesity-related health messages. International Journal of Obesity 2012; http://dx.doi.org/10.1038/ijo.2012.156. 74. Matthews KA, Salomon K, Kenyon K et al. Unfair treatment, discrimination, and ambulatory blood pressure in black and white adolescents. Health Psychology 2005; 24: 258–265.
R.M. Puhl, K.M. King / Best Practice & Research Clinical Endocrinology & Metabolism 27 (2013) 117–127
127
75. Tsenkova VK, Carr D, Schoeller DA et al. Perceived weight discrimination amplifies the link between central adiposity and nondiabetic glycemic control (HbA1c). Annals of Behavioral Medicine 2011; 41: 243–251. 76. Lewis TT, Kravitz HM, Janssen I et al. Self-reported experiences of discrimination and visceral fat in middle-aged AfricanAmerican and Causcasian women. American Journal of Epidemiology. 2011; 173: 1223–1231. 77. Amy NK, Aalborg A, Lyons P et al. Barriers to routine gynecological cancer screening for White and African-American obese women. International Journal of Obesity 2006; 30: 147–155. 78. Puhl RM, Peterson JL & Luedicke J. Parental perceptions of weight terminology that providers use with youth. Pediatrics 2011; 128: e786–e793. 79. Puhl RM, Peterson JL & Luedicke J. Motivating or stigmatizing? Public perceptions of language about weight used by health providers. International Journal of Obesity 2011; http://dx.doi.org/10.1038/ijo.2012.110. 80. McCormack LA, Laska MN, Gray C et al. Weight-related teasing in a racially diverse sample of sixth-grade children. Journal of the American Dietetic Association 2011; 111: 431–436. 81. Quinlan NP, Hoy MB & Costanzo PR. Sticks and stones: the effects of teasing on psychosocial functioning in an overweight treatment-seeking sample. Social Development 2009; 18: 24. 82. Eaton DK, Lowry R, Brener ND et al. Associations of body mass index and perceived weight with suicide ideation and suicide attempts among US high school students. Archives of Pediatrics & Adolescent Medicine 2005; 159: 513–519. 83. Falkner NH, Neumark-Sztainer D, Story M et al. Social, educational, and psychological correlates of weight status in adolescents. Obesity Research 2001; 9: 33–42. 84. Strauss CC, Smith K, Frame C et al. Personal and interpersonal characteristics associated with childhood obesity. Journal of Pediatric Psychology 1985; 10: 337–343. 85. Strauss RS & Pollack HA. Social marginalization of overweight children. Archives of Pediatrics Adolescent Medicine 2003; 157: 746–752. 86. Pierce JW & Wardle J. Cause and effect beliefs and self-esteem of overweight children. Journal of Child Psychology and Psychiatry 1997; 38: 645–650. 87. Puhl RM & Luedicke J. Weight-based victimization among adolescents in the school setting: emotional reactions and coping behaviors. Journal of Youth and Adolescence 2012; 41: 27–40. 88. Libbey HP, Story MT, Neumark-Sztainer DR et al. Teasing, disordered eating behaviors, and psychological morbidities among overweight adolescents. Obesity 2008; 16: S24–S29. 89. Haines J, Neumark-Sztainer D, Eisenberg ME et al. Weight teasing and disordered eating behaviors in adolescents: longitudinal findings from Project EAT (Eating Among Teens). Pediatrics 2006; 117: 209–215. 90. Matthews KA, Salomon K, Brady SS et al. Cardiovascular reactivity to stress predicts future blood pressure in adolescence. Psychosomatic Medicine 2003; 65: 410–415. 91. Gray WN, Janicke DM, Ingerski LM et al. The impact of peer victimization, parent distress and child depression on barrier formation and physical activity in overweight youth. Journal of Developmental & Behavioral Pediatrics 2008; 29: 26–33. 92. Storch EA, Milsom VA, DeBraganza N et al. Peer victimization, psychosocial adjustment, and physical activity in overweight and at-risk-for-overweight youth. Journal of Pediatric Psychology 2007; 32: 80–89. 93. Peterson JL, Puhl RM & Luedicke J. An experimental assessment of physical educators’ expectations and attitudes: the importance of student weight and gender. Journal of School Health 2012; 82: 432–440. 94. Farhat T, Iannotti RJ & Simons-Morton BG. Overweight, obesity, youth, and health-risk behaviors. American Journal of Preventive Medicine 2010; 38: 258–267. 95. Goldbacher EM, Matthews KA & Salomon K. Central adiposity is associated with cardiovascular reactivity to stress in adolescents. Health Psychology 2005; 24: 375. 96. C.S. Mott Children’s Hospital. Bullying worries parents of overweight and obese children. C.S. Mott Children’s Hospital, the University of Michigan Department of Pediatrics and Communicable Diseases, and the University of Michigan Child Health and Evaluation Research (CHEAR) Unit, 2008.