Stigma Experienced by Children and Adolescents With Obesity

Weight Stigma in Youth

Weight stigma among youth is most often experienced as victimization, teasing, and bullying. In the school setting, weight-based bullying is among the most frequent forms of peer harassment reported by students. As early as preschool, young children attribute negative characteristics and stereotypes to peers with larger body sizes.^11,12 By elementary school, negative weight-based stereotypes are common. Students are less likely to offer help to peers with overweight or obesity, and those with overweight or obesity are more likely to be bullied than are students of a healthier weight.^12–14 The likelihood of being targeted by verbal, relational, and physical victimization from peers increases with a student’s BMI percentile. Longitudinal evidence demonstrates that weight status significantly predicts future victimization, with youth of the highest weight being the most vulnerable to bullying.¹⁵ Recent evidence demonstrates that adolescents report the primary reason their peers are teased or bullied at school is because of their weight.¹⁶ Self-reported experiences of bullying, even among racially diverse samples of adolescents, indicate weight-based harassment is the most prevalent form of harassment reported by girls and the second-most common form of harassment among boys.¹⁷ A study of adolescents seeking weight loss treatment found that 71% reported being bullied about their weight in the past year, and more than one-third indicated that the bullying had persisted for >5 years.⁹

Weight Stigma and Parents and Educators

Perspectives of parents and educators have similarly identified weight-based bullying as a prevalent and problematic issue. A 2011 national study by the National Education Association examined perspectives of bullying among >5000 educators and found that weight-based bullying was viewed by teachers as the most problematic form of bullying in the classroom, more so than bullying because of a student’s sex, sexual orientation, or disability.¹⁸ In a national study of parents, having overweight was perceived by parents to be the most common reason youth are bullied, and these perspectives remained consistent regardless of their children’s weight status.¹⁹ Furthermore, a recent multinational study (including the United States, Canada, Australia, and Iceland) showed that adults across these countries consistently viewed having overweight as the most common reason youth are bullied.²⁰ Thus, reports by students, educators, and parents all point to weight-based bullying as a significant problem in the school setting.

Unfortunately, weight-based victimization of youth extends beyond peer relationships. Increasing evidence indicates educators can be sources of weight stigma. Experimental research shows that teachers have lower expectations of students with obesity than they have of students without obesity, including expectations of inferior physical, social, and academic abilities.²¹ Data from 5 waves of the Early Childhood Longitudinal Study, Kindergarten found that weight status in students was more negatively related to teachers’ assessments of their academic performance than to their test scores, indicating that teachers rate academic performance of students with obesity as worse than their test performance suggests.²² Self-report studies have additionally demonstrated negative weight-related stereotypes and beliefs among educators in the school setting.^23–26

Of concern, parents have also been identified as a source of weight-based victimization toward youth with obesity. In a survey study of adolescents attending weight-loss camps, 37% reported they had been teased or bullied about their weight by a parent.⁹ Survey researchers assessing experiences of weight stigma among women with obesity found that family members were reported to be the most prevalent interpersonal source of weight-stigma incidents, with 53% reporting weight stigma from their mothers and 44% reporting it from their fathers.²⁷ Weight stigma expressed by parents can have a lasting effect on children, who continue to report emotional consequences from these experiences through adulthood.²⁸

Weight Stigma and the Media

Beyond the school and home settings, youth are additionally vulnerable to weight stigma through the media. Content analyses of popular children’s television shows and movies reinforce weight stigma through stereotypical portrayals of characters who appear to have larger body sizes. Characters who are visually slim in children’s media are often portrayed as being kind, popular, and attractive, but characters with larger body sizes are depicted as aggressive, unpopular, evil, unhealthy, and the target of humor or ridicule.^29–31 A content analysis of recent children’s movies found 70% included weight-related stigmatizing content, of which 90% targeted characters with obesity.³² Similarly, research examining popular adolescent television shows identified a significantly higher proportion of weight-stigmatizing content in youth-targeted shows (50%) compared with shows targeting a general audience (38.3%).³³ Given that youth spend multiple hours per day watching television and other media, there is a considerable likelihood they are exposed to negative weight-based stereotypes and stigma.³⁴ Furthermore, research has documented associations between greater media exposure among youth and increased expressions by those youth of weight stigma toward peers with overweight and obesity.³⁵ Taken together, this evidence highlights youth-targeted media as sources of weight-based stereotypes that may reinforce and add to stigmatizing messages communicated to children at school and home.

Weight Stigma in Health Care

Research shows that health care professionals express weight stigma toward patients with obesity, and patients with obesity frequently feel stigmatized in health care settings.³⁶ Some research has found that more than two-thirds of women with overweight or obesity report being stigmatized about their weight by doctors.²⁷ Health care professionals, including physicians, nurses, dietitians, psychologists, and medical trainees, self-report bias and prejudice toward patients with obesity.^8,37 Research shows that physicians associate obesity with noncompliance and decreased medication adherence, hostility, dishonesty, and poor hygiene. They often view patients with obesity as being lazy, lacking self-control, and being less intelligent.^8,38 Furthermore, this prejudice negatively affects quality of care and can result in patients with obesity being less likely to seek preventive care and delaying or canceling appointments.^39–41 Physicians spend less time and engage in less discussion in office visits with patients with obesity than they do with patients with a lower BMI and are more reluctant to perform preventive health screenings, such as pelvic examinations, cancer screenings, and mammograms, for patients with obesity. Psychologists have been shown to ascribe more pathology, more negative and severe symptoms, and worse prognosis to patients with obesity than to those at a healthier weight but with otherwise similar behavioral health histories.^8,36,41 Anecdotal reports in the news suggest that patients have been denied care because they have obesity, which suggests a need for future studies exploring this discriminatory practice.⁴² Additionally, patients with obesity have reported not being provided with appropriate-sized medical equipment, such as blood pressure cuffs and patient gowns, which results in a less welcoming clinical environment and affects the quality of the health care that is provided.^8,38,43

When it comes to youth, even nuances in the language doctors use to discuss body weight with patients can lead to stigma and health care avoidance. Parental perceptions of words commonly used to describe excess body weight were examined in a national study of parents of children 2 to 18 years of age.⁴⁴ Parents were asked to evaluate 10 common words regarding the extent to which each word was desirable, stigmatizing, blaming, or motivating for weight loss. The terms “fat,” “obese,” and “extremely obese” were rated as the most undesirable, stigmatizing, blaming, and least motivating. In contrast, more neutral words like “weight” or “unhealthy weight” were rated as the most desirable and motivating for weight loss.^44–46 When parents were asked how they would react if a doctor referred to their children’s weight in a stigmatizing way, 34% responded that they would switch doctors, and 24% stated that they would avoid future medical appointments for their children.⁴⁴ Limited literature has evaluated how health care professionals might most effectively and sensitively discuss weight with their patients and families and also with whom pediatric patients prefer to talk with about their weight.^47,48 These findings merit further study and underscore the importance of how health care professionals communicate with patients about obesity and weight-related health.

Traditionally, medical school and residency education have provided limited training regarding successful approaches to encouraging health behavior change (eg, motivational interviewing) and addressing obesity in patients and their families, leading health care professionals to report that they do not feel competent or comfortable discussing weight with their patients.^49–51 More training is needed for trainees and practicing health care professionals regarding effective approaches to empowering children and families to make healthy changes. There are different approaches to educating medical students and health care professionals about weight stigma, such as educational strategies that emphasize the complex causes of obesity (eg, biological, genetic, and environmental contributors beyond personal control), communication skills training, interacting with virtual standardized patients, and using brief educational films, role play, and dramatic readings in addition to traditional lecture-style learning.^3,52–57 These approaches have been tested in different formats and can be incorporated into health care professional training programs.

Emotional and Psychological Effects

Weight stigma poses numerous consequences for the psychological and physical health of children and adolescents, including adverse outcomes that may reinforce unhealthy behaviors that promote obesity and weight gain. Experiences of weight-based teasing and bullying increase the risk for a range of emotional and psychological consequences for youth. Evidence has documented increased vulnerability to depression, anxiety, substance use, low self-esteem, and poor body image among youth who are teased or bullied about their weight.^58–62 These findings persist after accounting for factors such as age, sex, BMI, and age of obesity onset, which suggests stigmatizing experiences rather than just body weight are contributing to these negative outcomes. Of concern, self-harm behaviors and suicidality are also higher among youth who have been teased or bullied about their weight compared with same-weight peers who have not been teased. In addition to higher suicidal attempts reported among adolescents with obesity, research has found that the odds of thinking about and attempting suicide are approximately 2 times higher among girls and boys who are teased about their weight compared with those who are not teased about their weight.^63,64

Social Isolation and Academic Outcomes

Weight-based teasing and bullying also contribute to social isolation and adverse academic outcomes for youth. Evidence from the National Longitudinal Study of Adolescent Health demonstrated that compared with students without overweight, adolescents with overweight or obesity are significantly more likely to experience social isolation and are less likely to be nominated as friends by peers.^65,66 Youth are keenly aware at an early age that their weight status may affect their social relationships; 1 study found that more than two-thirds of 9- to 11-year-old children who perceived themselves as having excess weight believed they would have more friends if they could lose weight.³⁷ Teasing that impairs social bonds may have an additional negative effect on academic performance. Weight-based teasing has been found to mediate the relationship between students’ higher BMI and poorer school performance⁶⁷ and may lead students to disengage from their school environment. In a recent study, adolescents who reported experiencing weight-based bullying during the previous year indicated that their grades were harmed by these experiences, and they avoided going to school to escape weight-based teasing and bullying.⁶⁸ The likelihood of students reporting these reactions increased by 5% per teasing incident even after accounting for sex, race, age, grades, and weight status.

Unhealthy Eating Behaviors

Weight-based victimization may reinforce unhealthy eating behaviors that contribute to increased body weight. Among boys and girls enrolled in weight-loss camps, those who reported weight-based teasing were more likely to engage in unhealthy eating behaviors and binge eating than were peers who were not teased.^69,70 Prospective research has demonstrated longitudinal associations between early experiences of weight-based teasing and later disordered eating behaviors.⁷¹ Other work has found links between weight-based teasing and disordered eating for both adolescent boys and girls across weight strata.⁶⁵ Among Hispanic and African American girls, weight-based teasing from peers and parents was associated with more emotional eating and binge eating.⁷² Retrospective research with young adult women has additionally demonstrated that those who experienced weight-based teasing in childhood are more likely to engage in unhealthy eating behaviors than peers who were not teased, and as the variety of weight-based teasing insults increased in childhood, so did the disordered eating patterns and current body weight status in adulthood.⁶⁷

Decreased Exercise and Physical Activity

Experiences of weight-based teasing and bullying have negative implications for exercise motivation and physical activity. Youth who experience more frequent weight-based teasing have decreased levels of physical activity.^73,74 Middle school students who report being teased about their weight have less self-confidence in being physically active and lower levels of physical fitness compared with peers who are not teased even after controlling for sociodemographic characteristics.⁷⁵ Furthermore, adolescents who report more emotional distress in response to experiences of weight-based teasing are more likely to cope with teasing by avoiding school activities, including physical activities and going to physical education class.⁷⁰ These findings raise additional concerns in light of recent research showing that as many as 85% of high school students report witnessing weight-based teasing toward their peers during gym class at school.¹⁹

Worsening Obesity

Emerging research has demonstrated associations between weight-based teasing and increased body weight status in youth. One study found that compared with girls who did not experience weight stigmatization, girls reporting previous experiences of weight stigmatization had a 64% to 66% increased risk of developing and/or worsening overweight or obesity.^76,77 During adolescence, teasing and hurtful weight labels from family members may be especially harmful; evidence from a diverse sample of girls found greater odds of obesity as a result of stigmatization from family members than from friends and teachers.⁷⁸ Recent longitudinal evidence additionally shows that weight-based teasing experienced by girls and boys in adolescence predicts higher BMI and obesity for both women and men 15 years later.⁷⁹ In addition, several recent longitudinal studies of adults have found that perceived weight stigma and discrimination increase the risk of developing and continuing to have obesity over time even after controlling for baseline BMI, sex, race, and socioeconomic factors.^80,81 Furthermore, emerging research reports that perceived pressure to be thin in adolescence is associated with a greater elevation of fasting insulin and poorer insulin sensitivity. The negative effect of emotional pressure on hyperinsulinemia was sustained even after controlling for fat mass and adiposity.⁸² Taken together, these findings raise significant concerns about the effects of weight stigma on health behaviors and outcomes of vulnerable youth.

Improving Clinical Practice

The American Academy of Pediatrics recommends that pediatricians engage in efforts to mitigate weight stigmatization at the practice level and beyond. The following recommendations offer practice-level strategies for pediatricians.

1. Role Modeling. It is important for pediatricians and pediatric health care professionals to demonstrate and model professional behavior with colleagues, staff, and trainees that is supportive and nonbiased toward children and families with obesity. These efforts should include the recognition and acknowledgment of the complex etiology of obesity, including genetic and socioeconomic factors, environmental contributors, community assets, family and cultural traditions, and individual choices. This recognition can help dispel common assumptions and stereotypes that place blame and judgment solely on individuals for having excess weight or difficulties achieving weight loss.

2. Language and Word Choice. It is important for pediatricians and pediatric health care professionals to use appropriate, sensitive, and nonstigmatizing language in communication about weight with youth, families, and other members of the pediatric health care team. Words can heal or harm, intentionally and unintentionally. Recent evidence shows that neutral words like “weight” and “body mass index” are preferred by adolescents with overweight and obesity, whereas terms like “obese,” “extremely obese,” “fat,” or “weight problem” induce feelings of sadness, embarrassment, and shame if parents use these words to describe their children’s body weight.^83,84 Furthermore, using people-first language is one step to help reduce the use of potentially stigmatizing language, and it is now emerging as the preferred standard with obesity as well as other diseases and disabilities. People-first language places the individual first before the medical condition or disability and involves using phrases such as “a child with obesity” rather than an “obese child.”

3. Clinical Documentation. Obesity is a medical diagnosis with real health consequences, so it is important for children and families to understand the current and future health risks associated with the degree to which a patient weighs more than what is healthy. However, this should be addressed with a balanced and empathetic approach so that the information is conveyed and understood in a sensitive and supportive manner. Using more neutral terms, such as “unhealthy weight and “very unhealthy weight,” both in clinical notes and when speaking to patients and family members can assist in these efforts. Electronic health records and medical coding nomenclature could consider using the terms “unhealthy weight” and “very unhealthy weight” instead of “obesity” and “morbid obesity” in problem lists to further support the use of patient-sensitive language during clinical encounters.

4. Behavior Change Counseling. Beyond specific word choice, it is recommended that patient-centered, empathetic behavior change approaches, such as motivational interviewing, be used as a framework to support patients and families in making healthy changes.^85–87 Through motivational interviewing, health care professionals collaboratively engage the patient and/or parents in determining their goals and addressing barriers to how they will achieve sustained health behavior change.

5. Clinical Environment. Pediatricians should create a safe, welcoming, and nonstigmatizing clinic space for youth with obesity and their families. This requires creating a supportive practice setting that accommodates patients of diverse body sizes, from the clinic entrance to the examination room (see Appendix 1).

6. Behavioral Health Screening. Addressing weight stigma in clinical practice also necessitates that pediatricians assess patients not only for physical but also emotional comorbidities and negative exposures associated with obesity, including bullying, low self-esteem, poor school performance, depression, and anxiety.^88–90 These are often overlooked but can be signs a child is experiencing weight-based bullying.

Advocating Against Weight Stigma

Creating a healthy environment in which patients live is critical to effectively address and prevent obesity. As part of these efforts, it is important to promote an environment that supports and empowers youth and families to be healthy rather than reinforcing societal shame or stigma directed toward those with obesity. Thus, pediatricians can be important advocates to reduce weight stigma in multiple settings.

1. Schools. Pediatricians can work with schools to ensure antibullying policies include protections for students who are bullied about their weight. Given that weight-based bullying is often absent in school policies, advocacy efforts by health care professionals could play an important role in reducing such bullying.

2. Youth-Targeted Media. It is important that pediatricians and pediatric health care professionals advocate for a responsible and respectful portrayal of individuals with obesity in the media. By speaking out (eg, opinions and commentaries, letters to editors, professional presentations, or commenting on social media) against stigmatizing depictions in the media, pediatric health care professionals can help increase the awareness of weight stigma that can be particularly damaging to children and can reinforce broader societal stigma.

3. Provider Training. It is important for pediatricians and professional entities to continue to advocate for the inclusion of training to address weight stigma in medical school and residency curricula and through ongoing continuing medical education programs for practicing physicians; and

4. Parents. It is important for pediatricians and pediatric health care professionals to work to empower families and patients to manage and address weight stigma in schools, communities, and their homes. Pediatricians can encourage parents of patients to actively inquire with their children’s teachers and school administrative staff to ensure that plans are in place to address weight-based victimization in their institutions. Parents should also be asked to consider potential weight stigma at home, of which friends and family members can be sources. Finally, because the rates of obesity are higher in communities that are socioeconomically challenged and in communities of color, additional stigma attributable to race, socioeconomics, and sex could further compound the weight stigma experienced by some individuals, families, and communities.⁹¹