The stigma of obesity: a review and update.
TL;DR: This review expands upon previous findings of weight bias in major domains of living, documents new areas where weight bias has been studied, and highlights ongoing research questions that need to be addressed to advance this field of study.
Abstract: Obese individuals are highly stigmatized and face multiple forms of prejudice and discrimination because of their weight (1,2). The prevalence of weight discrimination in the United States has increased by 66% over the past decade (3), and is comparable to rates of racial discrimination, especially among women (4). Weight bias translates into inequities in employment settings, health-care facilities, and educational institutions, often due to widespread negative stereotypes that overweight and obese persons are lazy, unmotivated, lacking in selfdiscipline, less competent, noncompliant, and sloppy (2,5–7). These stereotypes are prevalent and are rarely challenged in Western society, leaving overweight and obese persons vulnerable to social injustice, unfair treatment, and impaired quality of life as a result of substantial disadvantages and stigma. In 2001, Puhl and Brownell published the first comprehensive review of several decades of research documenting bias and stigma toward overweight and obese persons (2). This review summarized weight stigma in domains of employment, health care, and education, demonstrating the vulnerability of obese persons to many forms of unfair treatment. Despite evidence of weight bias in important areas of living, the authors noted many gaps in research regarding the nature and extent of weight stigma in various settings, the lack of science on emotional and physical health consequences of weight bias, and the paucity of interventions to reduce negative stigma. In recent years, attention to weight bias has increased, with a growing recognition of the pervasiveness of weight bias and stigma, and its potential harmful consequences for obese persons. The aim of this article is to provide an update of scientific evidence on weight bias toward overweight and obese adults through a systematic review of published literature since the 2001 article by Puhl and Brownell. This review expands upon previous findings of weight bias in major domains of living, documents new areas where weight bias has been studied, and highlights ongoing research questions that need to be addressed to advance this field of study. A systematic literature search of studies published between January 2000 and May 2008 was undertaken on computerized psychological, medical, social science, sport, and education databases including PsycINFO, PubMed, SCOPUS, ERIC, and SPORTDiscus. The following keyword combinations were used: weight, obese, obesity, overweight, BMI, fat, fatness, size, heavy, large, appearance, big, heavyweight, bias, biased, discrimination, discriminatory, discriminate, stigma, stigmatized, stigmatization, prejudice, prejudicial, stereotype(s), stereotypical, stereotyping, victimization, victimize(d), blame(d), blaming, shame(d), shaming, teasing, tease(d), unfair, bully, bullying, harassment, assumptions, attributions, education, health, health care, sales, employment, wages, promotion, adoption, jury, customer service, housing, media, television. Reference lists of retrieved articles and books were also reviewed, and manual searches were conducted in the databases and journals for authors who had published in this field. Most studies retrieved for this review were published in the United States. Any articles published internationally are noted with their country of origin. Research on weight stigma in adolescents and children was excluded from this review, as this literature was recently reviewed elsewhere (8). Unpublished manuscripts and dissertations were also excluded. In addition, issues pertaining to measurement of weight stigmatization, and demographic variables affecting vulnerability to weight bias such as gender, age, race, and body weight are not addressed in this review. This article instead primarily reviews the evidence of specific areas where weight bias occurs toward adults and its consequences for those affected. This article is organized similarly to the first review published by Puhl and Brownell (2), with sections on weight bias in settings of employment, health care, and education. New sections have been added including weight bias in interpersonal relationships and the media, as well as psychological and physical health consequences of weight bias, and the status of stigma-reduction research. As with the 2001 article, this review also provides an update on legal initiatives to combat weight discrimination, and outlines specific questions for future research.
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TL;DR: This work provides illustrative evidence on the health consequences of stigma and presents a conceptual framework describing the psychological and structural pathways through which stigma influences health.
Abstract: Bodies of research pertaining to specific stigmatized statuses have typically developed in separate domains and have focused on single outcomes at 1 level of analysis, thereby obscuring the full significance of stigma as a fundamental driver of population health. Here we provide illustrative evidence on the health consequences of stigma and present a conceptual framework describing the psychological and structural pathways through which stigma influences health. Because of its pervasiveness, its disruption of multiple life domains (e.g., resources, social relationships, and coping behaviors), and its corrosive impact on the health of populations, stigma should be considered alongside the other major organizing concepts for research on social determinants of population health.
1,768 citations
TL;DR: It is proposed that weight stigma is not a beneficial public health tool for reducing obesity, but rather, stigmatization of obese individuals threatens health, generates health disparities, and interferes with effective obesity intervention efforts.
Abstract: Stigma and discrimination toward obese persons are pervasive and pose numerous consequences for their psychological and physical health. Despite decades of science documenting weight stigma, its public health implications are widely ignored. Instead, obese persons are blamed for their weight, with common perceptions that weight stigmatization is justifiable and may motivate individuals to adopt healthier behaviors. We examine evidence to address these assumptions and discuss their public health implications. On the basis of current findings, we propose that weight stigma is not a beneficial public health tool for reducing obesity. Rather, stigmatization of obese individuals threatens health, generates health disparities, and interferes with effective obesity intervention efforts. These findings highlight weight stigma as both a social justice issue and a priority for public health.
1,474 citations
TL;DR: Dissemination of information about obesity genetics may have neither a beneficial nor a harmful impact on how overweight individuals perceive themselves, but some overweight individuals may be interested in receiving personalized genetic information.
Abstract: Background/Aims: Increasing public awareness of obesity genetics could have beneficial or harmful effects on overweight individuals. This study examined the impact of genetic information on weight-related cognitions as well as interest in personalized genetic information about obesity among overweight individuals. Methods: Online survey respondents (n = 655) were randomly assigned to read either genetic, gene-environment, or nongenetic obesity causal information. Fifty-two percent of the participants were female, 82.4% were White, 45% had an annual income of USD Results: Participants in the genetic and gene-environment conditions were more likely to believe genetics increase obesity risk than participants in the nongenetic condition (both p Conclusion: Dissemination of information about obesity genetics may have neither a beneficial nor a harmful impact on how overweight individuals perceive themselves. Some overweight individuals may be interested in receiving personalized genetic information. The actual effects of obesity genetic information being incorporated into public health messages and of personalized genetic information on obesity prevention and treatment interventions remain to be seen.
925 citations
TL;DR: The empirical evidence from all relevant disciplines regarding obesity stigma is critically reviewed in order to determine the implications of obesity stigma for healthcare providers and their patients with obesity and identify strategies to improve care for patients with Obesity.
Abstract: The objective of this study was to critically review the empirical evidence from all relevant disciplines regarding obesity stigma in order to (i) determine the implications of obesity stigma for healthcare providers and their patients with obesity and (ii) identify strategies to improve care for patients with obesity. We conducted a search of Medline and PsychInfo for all peer-reviewed papers presenting original empirical data relevant to stigma, bias, discrimination, prejudice and medical care. We then performed a narrative review of the existing empirical evidence regarding the impact of obesity stigma and weight bias for healthcare quality and outcomes. Many healthcare providers hold strong negative attitudes and stereotypes about people with obesity. There is considerable evidence that such attitudes influence person-perceptions, judgment, interpersonal behaviour and decision-making. These attitudes may impact the care they provide. Experiences of or expectations for poor treatment may cause stress and avoidance of care, mistrust of doctors and poor adherence among patients with obesity. Stigma can reduce the quality of care for patients with obesity despite the best intentions of healthcare providers to provide high-quality care. There are several potential intervention strategies that may reduce the impact of obesity stigma on quality of care.
757 citations
Cites background from "The stigma of obesity: a review and..."
...Obesity is a commonly and strongly stigmatized characteristic (12,13)....
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...Despite the high prevalence of obesity (approximately one-third of the US adult population (17) ), individuals with obesity are frequently the targets of prejudice, derogatory comments and other poor treatment in a variety of settings, including health care (12,18)....
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TL;DR: The global overweight and obesity prevalence has increased dramatically since 1990, for example in preschool-age children, from approximately 4% in 1990 to 7% in 2010, and may reach 9% or 60 million people in 2020 if this trend continues.
Abstract: This paper describes the current prevalence and time trends of childhood obesity worldwide, and the association between childhood obesity and socio-economic status (SES). Childhood obesity has become a global public health crisis. The prevalence is highest in western and industrialized countries, but still low in some developing countries. The prevalence also varies by age and gender. The WHO Americas and eastern Mediterranean regions had higher prevalence of overweight and obesity (30–40%) than the European (20–30%), south-east Asian, western Pacific, and African regions (10–20% in the latter three). A total of 43 million children (35 million in developing countries) were estimated to be overweight or obese; 92 million were at risk of overweight in 2010. The global overweight and obesity prevalence has increased dramatically since 1990, for example in preschool-age children, from approximately 4% in 1990 to 7% in 2010. If this trend continues, the prevalence may reach 9% or 60 million people in 2...
629 citations
Cites background from "The stigma of obesity: a review and..."
...…risk, predominately using cross-sectional survey data collected in various population groups across different countries (Beydoun & Wang., 2009; McLaren, 2007; Monteiro et al., 2004; Puhl & Heuer, 2009; Shrewsbury & Wardle, 2008; Sobal & Stunkard, 1989; Wang & Zhang, 2006; Zhang & Wang, 2004, 2007)....
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References
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TL;DR: Information on discriminatory attitudes and behaviors against obese individuals is reviewed, integrating this to show whether systematic discrimination occurs and why, and needed work in the field is discussed.
Abstract: This article reviews information on discriminatory attitudes and behaviors against obese individuals, integrates this to show whether systematic discrimination occurs and why, and discusses needed work in the field. Clear and consistent stigmatization, and in some cases discrimination, can be documented in three important areas of living: employment, education, and health care. Among the findings are that 28% of teachers in one study said that becoming obese is the worst thing that can happen to a person; 24% of nurses said that they are "repulsed" by obese persons; and, controlling for income and grades, parents provide less college support for their overweight than for their thin children. There are also suggestions but not yet documentation of discrimination occurring in adoption proceedings, jury selection, housing, and other areas. Given the vast numbers of people potentially affected, it is important to consider the research-related, educational, and social policy implications of these findings.
2,069 citations
"The stigma of obesity: a review and..." refers background or methods in this paper
...This article is organized similarly to the first review published by Puhl and Brownell (2), with sections on weight bias in settings of employment, health care, and education....
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..., physicians, nurses, psychologists, and medical students) possess negative attitudes toward obese patients, including beliefs that obese patients are lazy, noncompliant, undisciplined, and have low willpower (2)....
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...Building upon the evidence reviewed by Puhl and Brownell (2), recent studies confirm that obese patients encounter prejudice, ambivalence, and oftentimes unsatisfactory treatment in health care....
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...Puhl and Brownell found that 32% of overweight and obese women (N = 2,449) reported experiencing weight stigma from a teacher or a professor, and 21% had experienced it more than once or multiple times (9)....
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...It will be important to identify the effect of weight bias in the media on public attitudes and behaviors, and to determine effective strategies to reduce stigmatizing content in the media. undErStudiEd domainS of wEigHt biaS In 2001, Puhl and Brownell noted several understudied domains in which obese persons may be vulnerable to weight discrimination, including public accommodations, jury selection, housing, and adoption (2)....
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TL;DR: Increasing body mass index is associated with a significant increase in the risk of cancer for 10 out of 17 specific types examined, and for colorectal cancer, malignant melanoma, breast cancer, and endometrial cancer, the effect ofBody mass index on risk differed significantly according to menopausal status.
Abstract: Objective To examine the relation between body mass index (kg/m2) and cancer incidence and mortality. Design Prospective cohort study. Participants 1.2 million UK women recruited into the Million Women Study, aged 50-64 during 1996-2001, and followed up, on average, for 5.4 years for cancer incidence and 7.0 years for cancer mortality. Main outcome measures Relative risks of incidence and mortality for all cancers, and for 17 specific types of cancer, according to body mass index, adjusted for age, geographical region, socioeconomic status, age at first birth, parity, smoking status, alcohol intake, physical activity, years since menopause, and use of hormone replacement therapy. Results 45 037 incident cancers and 17 203 deaths from cancer occurred over the follow-up period. Increasing body mass index was associated with an increased incidence of endometrial cancer (trend in relative risk per 10 units=2.89, 95% confidence interval 2.62 to 3.18), adenocarcinoma of the oesophagus (2.38, 1.59 to 3.56), kidney cancer (1.53, 1.27 to 1.84), leukaemia (1.50, 1.23 to 1.83), multiple myeloma (1.31, 1.04 to 1.65), pancreatic cancer (1.24, 1.03 to 1.48), non-Hodgkin9s lymphoma (1.17, 1.03 to 1.34), ovarian cancer (1.14, 1.03 to 1.27), all cancers combined (1.12, 1.09 to 1.14), breast cancer in postmenopausal women (1.40, 1.31 to 1.49) and colorectal cancer in premenopausal women (1.61, 1.05 to 2.48). In general, the relation between body mass index and mortality was similar to that for incidence. For colorectal cancer, malignant melanoma, breast cancer, and endometrial cancer, the effect of body mass index on risk differed significantly according to menopausal status. Conclusions Increasing body mass index is associated with a significant increase in the risk of cancer for 10 out of 17 specific types examined. Among postmenopausal women in the UK, 5% of all cancers (about 6000 annually) are attributable to being overweight or obese. For endometrial cancer and adenocarcinoma of the oesophagus, body mass index represents a major modifiable risk factor; about half of all cases in postmenopausal women are attributable to overweight or obesity.
1,348 citations
"The stigma of obesity: a review and..." refers background in this paper
...These findings are concerning, especially given the incidence of cancer and mortality rates in obese individuals (77)....
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TL;DR: Fatism appears to behave much like symbolic racism, but with less of the negative social desirability of racism, and three commonalities between antifat attitudes and racism were explored.
Abstract: Prejudice against fat people was compared with symbolic racism. An anti-fat attitudes questionnaire was developed and used in several studies testing the notion that antipathy toward fat people is part of an "ideology of blame." Three commonalities between antifat attitudes and racism were explored: (a) the association between values, beliefs, and the rejection of a stigmatized group, (b) the old-fashioned antipathy toward deviance of many sorts, and (c) the lack of self-interest in out-group antipathy. Parallels were found on all 3 dimensions. No in-group bias was shown by fat people. Fatism appears to behave much like symbolic racism, but with less of the negative social desirability of racism.
1,303 citations
"The stigma of obesity: a review and..." refers background or result in this paper
...Belief in the controllability of weight often predicts stigmatizing attitudes (123,124)....
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...These findings parallel previous work documenting improved attitudes following an intervention that highlighted external, noncontrollable reasons for obesity (123)....
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TL;DR: This report reviews existing research on weight stigma in children and adolescents, with attention to the nature and extent of weight bias toward obese youths and to the primary sources of stigma in their lives, including peers, educators, and parents.
Abstract: Preventing childhood obesity has become a top priority in efforts to improve our nation’s public health. Although much research is needed to address this health crisis, it is important to approach childhood obesity with an understanding of the social stigma that obese youths face, which is pervasive and can have serious consequences for emotional and physical health. This report reviews existing research on weight stigma in children and adolescents, with attention to the nature and extent of weight bias toward obese youths and to the primary sources of stigma in their lives, including peers, educators, and parents. The authors also examine the literature on psychosocial and physical health consequences of childhood obesity to illustrate the role that weight stigma may play in mediating negative health outcomes. The authors then review stigma-reduction efforts that have been tested to improve attitudes toward obese children, and they highlight complex questions about the role of weight bias in childhood obesity prevention. With these literatures assembled, areas of research are outlined to guide efforts on weight stigma in youths, with an emphasis on the importance of studying the effect of weight stigma on physical health outcomes and identifying effective interventions to improve attitudes.
1,277 citations
"The stigma of obesity: a review and..." refers background or result in this paper
...Latner JD, Wilson GT, Jackson ML, Stunkard AJ....
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...Similarly, Latner and colleagues examined attitudes in New Zealand adolescents (N = 261) and found that media exposure (including videogame playing, television viewing, and magazine use) was significantly associated with stigmatizing attitudes toward obese youth (122). advertising Another source of weight bias stems from the ubiquitous advertising of weight loss products and programs....
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...Latner JD, Rosewall JK, Simmonds MB. Childhood obesity stigma: association with television, videogame, and magazine exposure....
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...It may be that weight bias creates higher levels of general stress, which in turn increases cardiovascular reactivity and vulnerability to negative health outcomes—see discussion by Puhl and Latner (8)....
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...Puhl RM, Latner JD. Stigma, obesity, and the health of the nation’s children....
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TL;DR: Results of 3 experiments suggest that feeling empathy for a member of a stigmatized group can improve attitudes toward the group as a whole and possible limits of the empathy-attitude effect are tested.
Abstract: Results of 3 experiments suggest that feeling empathy for a member of a stigmatized group can improve attitudes toward the group as a whole. In Experiments 1 and 2, inducing empathy for a young woman with AIDS (Experiment 1) or a homeless man (Experiment 2) led to more positive attitudes toward people with AIDS or toward the homeless, respectively. Experiment 3 tested possible limits of the empathy-attitude effect by inducing empathy toward a member of a highly stigmatized group, convicted murderers, and measuring attitudes toward this group immediately and then 1-2 weeks later. Results provided only weak evidence of improved attitudes toward murderers immediately but strong evidence of improved attitudes 1-2 weeks later.
1,177 citations
"The stigma of obesity: a review and..." refers background in this paper
...Given that empathy induction has been demonstrated to be an effective strategy for promoting positive attitudes toward other stigmatized groups (186), it may be that certain forms of bias, such as obesity, are resistant to these strategies....
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