Social stigma of obesity

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The social stigma of obesity has created negative psychosocial impacts and has caused disadvantages for overweight and obese people. Weight stigma is similar and has been broadly defined as bias (prejudicial and negative attitudes, beliefs, and/or stereotypes) or discriminatory behaviors targeted at individuals, because of their weight.[1][2] Such social stigmas can span one's entire life, as long as excess weight is present, starting from a young age and lasting into adulthood.[3] Several studies from across the world (e.g., United States, University of Marburg, University of Leipzig) indicate overweight and obese individuals experience higher levels of stigma relative to their thinner counterparts. In addition, they marry less often, experience fewer educational and opportunities, and on average earn a lesser income than normal weight individuals.[3] Although public support regarding disability services, civil rights and anti-workplace discrimination laws for obese individuals have gained support across the years,[3] overweight and obese individuals still experience discrimination, which may have implications to physiological and psychological health. These issues are compounded with the significant negative physiological effects associated with obesity.[4]

Obesity stigma stands to be one of the few acceptable forms of discrimination in Western society.

Prevalence[edit]

Research indicates that self-reported incidents of weight-based discrimination, has increased in the last few decades.[5] Individuals who are subjected to weight-related stigma, appear to be rated more negatively when compared with other groups, such as sexual minorities, and those with mental illness.[6]

Characteristics of Weight-Related Stigma[edit]

Weight-related stigma can be characterised by the following aspects:

  1. An individual does not have to be overweight or obese, to experience weight-related stigma.[7]
  2. Studies have indicated that experiencing weight stigma may perpetuate the associated behaviours. This suggests that being subjected to weight-related stigma, may exacerbate the targeted condition.
  3. Many groups who are subjected to stigmatisation, tend to be minorities. Overweight and obese individuals make up the majority of the population in the United States, and in other parts of the world.[8]
  4. Individuals who are overweight or obese, tend to devalue their own in-group, and prefer the out-group (i.e. thinner individuals).[9]

Theoretical explanations for weight-stigma[edit]

In order to understand weight-biased attitudes, theories have been proposed to explain the discrimination. Crandall’s Social Ideology Perspective draws on traditional North American values of self-determination, individualism and self-discipline. Based on these values, anti-fat attitudes may derive from directing blame towards individuals who are overweight.[10] Similarly, the attribution theory suggests that attitudes towards obese individuals are dependent on how much control they are perceived to have over their weight.[2] Throughout the literature, numerous studies have shown support for this theory. One study conducted a multinational examination of weight bias across four countries (Canada, United States, Iceland, and Australia) with comparable obesity rates.[11] The study found that attributions of behavioral causes of obesity were associated with greater weight bias. Further, these individuals were more likely to view obesity as being due to lack of willpower. There appears to be decreased weight bias when weight was attributed to factors that were less within the individual’s control, or when individuals are perceived as trying to lose weight.[12]

Weight discrimination[edit]

Weight stigma is present in multiple settings including healthcare, education, interpersonal situations, multiple media forms and outlets, and across many levels of employment.[2]

In the media[edit]

Media, in general, under represents overweight individuals and when these roles are present, they are often minor, stereotyped roles. They are more commonly seen eating, and are less likely to be involved in a romantic relationship compared to the average weight television character.[2]

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

In education[edit]

In regards to more direct weight bias, obese individuals were 40-50% more likely to report major discrimination compared to those of average weight across a multitude of settings.[14] More specifically, studies have shown that those who are overweight face discrimination throughout the educational and employment systems. In the educational setting, those who are overweight as youth often face peer rejection.[15] As individuals grow older they may be less likely to be admitted into a college compared to average weight persons, and in some cases, individuals were admitted to academic institutions and dismissed due to weight.[2][6] Research suggests that within the classroom teachers may perceive overweight individuals’ work more poorly compared to average weight individuals, and the attention the teacher provides to these two groups may differ.[2] Research has also found that overweight females receive less financial support for education from their families than average weight females, after controlling for ethnicity, family size, income, and education.[2][6]

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

In employment[edit]

Studies suggest that obese individuals are less likely to be hired and once hired, have greater termination rates than average weight individuals.[2][6] Specifically, a national survey found that obese individuals were 26% more likely not to be hired, not receive a promotion, or to be fired compared to average weight persons.[14] Such outcomes may be a result of employers viewing them as less agreeable, less competent and lazier than average weight individuals.[2][6]

Weight stigma leads to difficulty obtaining a job, worse job placement, lower wages and compensation, unjustified denial of promotions, harsher discipline, unfair job termination, and commonplace derogatory jokes and comments from coworkers and supervisors.[2] In their review, Puhl et al. find that employees with overweight and obesity report their weight as the most influential factor contributing to losing their job.[2] Another review by Giel and colleagues (2010) found that certain stereotypes about employees with overweight and obesity are highly endorsed by employers and supervisors, in particular that they have poorer job performance and that they lack interpersonal skills, motivation, and self-control.[16]

In politics[edit]

New Jersey Governor Chris Christie is a politician who may have suffered from weight related discrimination at times during his political career.

A study, by Michigan State University researchers, shows evidence overweight political candidates tend to receive fewer votes than their thinner opponents. The researchers analyzed data from the 2008 and 2012 U.S. Senate elections. Using a previously established scientific method, research assistants determined from color photos whether the candidates in 126 primary and general elections were normal weight, overweight or obese.

Both obese men and women were often less likely to get on the ballot in the first place. When it came to merely being overweight, women were seen underrepresented on the ballot, though men were not. This is consistent with previous research showing men who are slightly heavy tend not to experience the same discrimination of a slightly overweight women.

However, when it came to the voting, both male and female candidates, whether obese or simply overweight, tend to get a lower share of the vote total than their more slender opponents. Some politicians have resorted to extreme weight loss measures, including surgery, to increase their elect-ability to political office. [17]

In healthcare[edit]

Medical professionals may be more likely to view obese individuals in negative terms such as weak willed, unsuccessful, hopeless, and non-compliant with their treatments. As such, these individuals may receive poorer care compared to average weight people. Doctors have reported less intervention and an avoidance of weight-related discussion with obese patients. Additionally, nurses have reported a reluctance to touch obese persons during treatment.[6] A national survey found that individuals who were overweight reported a 3xs more likely to be denied medical care than average weight people.[14] Further, health professionals who specialize in obesity showed strong implicit and explicit anti-fat bias as measured by self-report and the Implicit Associations Test (IAT).[18] However, such biases were mixed amongst dietitians and nutritionists.[19]

In their 2009 review, Puhl and colleagues found that many studies provide evidence supporting the notion that health professionals (including doctors, nurses, medical students, fitness professional, and dietitians) consistently endorse negative stereotypes about patients with overweight and obesity, in particular ascribing to them culpability for their weight status.[2] Weight stigma in the healthcare settings leads to impaired patient-provider communication, poorer doctor-patient relationships, poorer medical care and treatment (for example doctors spending less time with patients), and avoidance of the healthcare system all together on the part of the patient.[2] However, it is important to point out that the evidence that has been reviewed thus far comes primarily from self-report studies. Therefore, Puhl and colleagues concluded that research examining actual health outcomes is needed.[2] Overall, the impact of weight stigma in healthcare has become so problematic that many scholars have suggested that obesity-prevention programs should make minimizing stigma a priority.[2][20]

Interpersonal situations[edit]

Although a less studied topic than employment and healthcare, several studies reviewed by Puhl and colleagues (2009) provide evidence that women with overweight and obesity, in particular, face weight stigma from many interpersonal sources including family, friends, and romantic partners.[2] Another recent review by Puhl and Suh (2015) also documented that in school settings weight-based bullying is one of the most prevalent types of harassment reported by parents, teachers, and students.[21] Experiencing interpersonal weight stigma is related to myriad negative physics and mental health consequences (see "Physical and Mental Health Consequences of Experiencing Weight Stigma" below).

In early development[edit]

This external stigmatization and its internalized effects have been examined across different age groups. Overweight and obese children and adolescents experience stigmatization from parents, teachers, and peers.[22] Peer stigmatization, especially, may be difficult for overweight adolescents considering the role of peer support in promoting identity development and self-esteem.[21] Some research suggests that negative attitudes about being overweight are even held by overweight and obese children themselves. Specifically, weight bias may become internalized and increase throughout childhood, then decrease and level-off during late adolescence and adulthood.[22]

Weight-based teasing in childhood and adolescence has been associated with a handful of costs to psychosocial health, including reduced self-esteem and lower self-concept,[22][23] higher rates of depression and anxiety disorders,[24][25][26] and even greater likelihood of endorsing suicidal thoughts.[22] Further, weight-based teasing has been associated with higher rates of binge eating and unhealthy weight control (e.g., fasting, self-induced vomiting, laxatives, diet pills, skipped meals, smoking).[22][27][28] Overweight adolescents who were bullied were also more likely to meet criteria for bulimia.[29]

A survey of 7,266 children aged 11 to 16 conducted by the World Health Organization reported higher rates of physical victimization (e.g., being shoved) with increasing body mass index among girls. Additionally, these results showed relational victimization (i.e., being excluded or having rumors spread about you) was reported more often at increasing body mass index by both girls and boys.[21] A separate survey of 7,825 students aged 11 to 17 also noted that, compared to average-weight peers, obese boys and overweight girls were more likely to be victims of bullying. Additionally, obese girls were more likely to be victims and perpetrators of bullying than their peers. Notably, overweight and obese adolescent girls also reported higher rates of smoking, drinking, and marijuana use relative to their normal-weight peers.[30]

Health-related outcomes associated with weight discrimination[edit]

In adulthood, individuals who experience weight discrimination are more likely to identify themselves as overweight regardless of their actual weight status.[31] The experience of weight stigma can function as motivation to avoid stigmatizing environments, and although it may motivate one to escape stigma through weight loss, it undermines one’s capacity to do so.[32] Researchers have linked weight stigma to decreases in physical activity,[31][33][34] decreases in seeking health care[34] and increases in maladaptive eating patterns such as binge eating.[32][34] In addition, those who have experienced weight stigma have shown altered cardiovascular reactivity, increased cortisol level, oxidative stress, and inflammation.[32]

In terms of psychological health, researchers demonstrated that obese individuals demonstrated lower sense of well-being relative to non-obese individuals if they had perceived weight stigmatization even after controlling for other demographic factors such as age and sex.[35] Overweight and obese individuals report experiencing forms of internalized stigma such as body dissatisfaction as well as decreased social support and feelings of loneliness.[36][37] In addition, similar to findings in adolescence, weight stigma in adulthood is associated with lower self-esteem, higher rates of depression, anxiety, and substance use.[32][34][36]

In both adults and children with overweight and obesity, several reviews of the literature have found that across a variety of studies, there is a consistent relationship between experiencing weight stigma and many negative mental and physical health outcomes.[2][10][38][13][39] These will be discussed separately in the sections below, although it should be noted that oftentimes physical and mental health consequences are intertwined, in particular those related to eating disorders.

Papadopoulos and Brennan (2015) recently found that across many reviewed studies, relationships emerged between experiencing weight stigma and both BMI and difficulty losing weight in weight loss treatment seeking adults.[38] However the findings are somewhat mixed. They also report evidence that experiencing weight stigma is related to poor medication adherence. Among weight loss treatment-seeking adults, experiencing weight stigma might exacerbate weight- and health-related quality of life.[38] This review along with reviews by Vartanian and Smyth (2013) and Puhl and Suh (2015) have also found that across several studies and in both adults and children, experiencing weight stigma is related to decreased exercise behavior overall, as well as decreased motivation to exercise, decreased exercise self-efficacy, and increased food craving and tendency to overeat.[10][38][21] It is important to note that these effects of weight stigma on exercise and physical activity emerge independent of Body Mass Index, suggesting that weight stigma becomes a unique barrier to physical activity outside of barriers that may be associated with overweight and obesity in particular. Finally, across many studies, Puhl and Suh (2015) also found that experiencing weight stigma is related to many physiological consequences as well, including increased blood pressure, augmented cortisol reactivity, elevated oxidative stress, impaired glycemic control/elevated HbA1c, and increased systemic inflammation,[21][39] all of which have notable consequences for physical health and disease.

Mental health and psychological consequences[edit]

Broadly speaking, experiencing weight stigma is associated with psychological distress. Papadopoulos's 2015 review of the literature found that across several studies, this distress can manifest in anxiety, depression, lowered self-esteem, and substance use disorders, both in weight loss treatment seeking individuals as well as community samples.[38] Many empirical reviews have found that weight stigma has clear consequences for individuals suffering from eating and weight disorders (including Anorexia Nervosa, Bulimia Nervosa, and Binge Eating Disorder), as it plays a unique role, over and above other risk factors, in perpetuating disordered eating psychopathology.[38][21][39] These results have emerged in both adult and adolescent samples and among both men and women. Notably, the studies included in these reviews reported their results emerging over and above the degree of overweight/obesity in their respective subjects, suggesting that weight stigma, in particular, and not just being overweight or obese, precipitates these negative outcomes.

Policy[edit]

Over the past few decades, many scholars have identified weight stigma as a long-standing form of social stigma and one of the last remaining socially acceptable forms of prejudice. It follows then that individuals with overweight and obesity as targets still face uniquely socially acceptable discrimination.[40][41] Civil rights legislation such as Title VII of the Civil Rights Act of 1964 prohibits discrimination based on race and several other domains, but weight is not included in this act. At the local level, only one state in the US (Michigan) has policy in place for prohibiting weight-related employment discrimination and very few local municipalities have human rights ordinances in place to protect body size.[2][42] Typically, the only type legislation that individuals with overweight and obesity can cite in lawsuits is related to disability. For example, the Americans with Disabilities Act is one such avenue, but as Puhl et al. (2009) report, it is difficult for many individuals with obesity to qualify as disabled according to the criteria included in this statute.[2]

Public health: a tool or a threat?[edit]

Although many health policy scholars and public health initiatives have suggested that weight stigma might motivate weight loss, the evidence from the existing literature largely does not support this notion. As cited above, experiencing weight stigma (both interpersonally as well as exposure to stigmatizing media campaigns) is consistently related to a lack of motivation to exercise and a propensity to overeat.[10][38][21] In a 2010 review examining whether weight stigma is an appropriate public health tool for treating and preventing overweight and obesity, Puhl and Heuer concluded that stigmatizing individuals with overweight and obesity is actually detrimental in three important ways: (1) it threatens actual physical health, (2) it perpetuates health disparities, and (3) it actually undermines obesity treatment and intervention initiatives.[43] In line with this, another recent review of the consequences of experiencing weight stigma, this one conducted by Puhl and Suh (2015), concluded that, considering the myriad negative physical and mental health consequences associated with experiencing of weight stigma, it should in fact be a target, instead of a tool, in obesity prevention and treatment.[21] These authors further recommend that a necessary first step in reducing weight stigma is raising a broader awareness of its negative consequences.[21]

References[edit]

  1. ^ Puhl, Rebecca M.; Brownell, Kelly D. (2003-11-01). "Psychosocial origins of obesity stigma: toward changing a powerful and pervasive bias". Obesity Reviews. 4 (4): 213–227. doi:10.1046/j.1467-789X.2003.00122.x. ISSN 1467-789X. 
  2. ^ a b c d e f g h i j k l m n o p q r s t u v w x y Puhl, Rebecca M.; Heuer, Chelsea A. (2009-05-01). "The Stigma of Obesity: A Review and Update". Obesity. 17 (5): 941–964. doi:10.1038/oby.2008.636. ISSN 1930-739X. 
  3. ^ a b c "Dicke sind faul und dumm" (in German). Süddeutsche Zeitung. August 11, 2008. Retrieved March 8, 2011. 
  4. ^ "The Health Effects of Overweight and Obesity". Center for Disease Control. August 11, 2011. Retrieved January 17, 2017. 
  5. ^ Andreyeva, Tatiana; Puhl, Rebecca M.; Brownell, Kelly D. (2008-05-01). "Changes in Perceived Weight Discrimination Among Americans, 1995–1996 Through 2004–2006". Obesity. 16 (5): 1129–1134. doi:10.1038/oby.2008.35. ISSN 1930-739X. 
  6. ^ a b c d e f Vartanian, Lenny R.; Smyth, Joshua M. (2013-01-04). "Primum Non Nocere: Obesity Stigma and Public Health". Journal of Bioethical Inquiry. 10 (1): 49–57. doi:10.1007/s11673-012-9412-9. ISSN 1176-7529. 
  7. ^ Carr, Deborah; Friedman, Michael A. (2005-09-01). "Is Obesity Stigmatizing? Body Weight, Perceived Discrimination, and Psychological Well-Being in the United States". Journal of Health and Social Behavior. 46 (3): 244–259. doi:10.1177/002214650504600303. ISSN 0022-1465. PMID 16259147. 
  8. ^ Ogden, Cynthia L; Carroll, Margaret D; Kit, Brian K; Flegal, Katherine M (26 February 2014). "Prevalence of childhood and adult obesity in the United States, 2011-2012". JAMA. 311 (8): 806–14. doi:10.1001/jama.2014.732. PMC 4770258Freely accessible. PMID 24570244. 
  9. ^ Latner, Janet D.; O'Brien, Kerry S.; Durso, Laura E.; Brinkman, L. A.; MacDonald, T. (2008-04-15). "Weighing obesity stigma: the relative strength of different forms of bias". International Journal of Obesity. 32 (7): 1145–1152. doi:10.1038/ijo.2008.53. ISSN 0307-0565. 
  10. ^ a b c d Puhl, R.M.; Brownell, K.D. "Stigma, discrimination, and obesity". Eating Disorders and Obesity: A Comprehensive Handbook. 
  11. ^ "A multinational examination of weight bias: Predictor of anti-fat attitudes across four countries". International Journal of Obesity. 39. doi:10.1038/ijo.2015.32. 
  12. ^ Beames, Joanne R.; Black, Melissa J.; Vartanian, Lenny R. "Prejudice toward individuals with obesity: Evidence for a pro-effort bias". Journal of Experimental Psychology: Applied. 22 (2): 184–195. doi:10.1037/xap0000079. 
  13. ^ a b c Puhl, Rebecca; Suh, Young (2015-04-01). "Health Consequences of Weight Stigma: Implications for Obesity Prevention and Treatment". Current Obesity Reports. 4 (2): 182–190. doi:10.1007/s13679-015-0153-z. ISSN 2162-4968. 
  14. ^ a b c Carr, Deborah; Friedman, Michael A. (2005-09-01). "Is Obesity Stigmatizing? Body Weight, Perceived Discrimination, and Psychological Well-Being in the United States". Journal of Health and Social Behavior. 46 (3): 244–259. doi:10.1177/002214650504600303. ISSN 0022-1465. PMID 16259147. 
  15. ^ Wardle, Jane; Cooke, Lucy. "The impact of obesity on psychological well-being". Best Practice & Research Clinical Endocrinology & Metabolism. 19 (3): 421–440. doi:10.1016/j.beem.2005.04.006. 
  16. ^ Giel, Katrin Elisabeth; Thiel, Ansgar; Teufel, Martin; Mayer, Jochen; Zipfel, Stephan (March 2010). "Weight Bias in Work Settings – a Qualitative Review". Obesity Facts. 3 (1): 33–40. doi:10.1159/000276992. 
  17. ^ https://www.sciencedaily.com/releases/2014/05/140519160753.htm.  Missing or empty |title= (help)
  18. ^ Schwartz, Marlene B.; Chambliss, Heather O'Neal; Brownell, Kelly D.; Blair, Steven N.; Billington, Charles (2003-09-01). "Weight Bias among Health Professionals Specializing in Obesity". Obesity Research. 11 (9): 1033–1039. doi:10.1038/oby.2003.142. ISSN 1550-8528. PMID 12972672. 
  19. ^ Jung, Franziska U. C. E.; Luck-Sikorski, Claudia; Wiemers, Nina; Riedel-Heller, Steffi G. (2015-10-14). "Dietitians and Nutritionists: Stigma in the Context of Obesity. A Systematic Review". PLOS ONE. 10 (10): e0140276. doi:10.1371/journal.pone.0140276. ISSN 1932-6203. PMC 4605484Freely accessible. PMID 26466329. 
  20. ^ MacLean, Lynne; Edwards, Nancy; Garrard, Michael; Sims-Jones, Nicki; Clinton, Kathryn; Ashley, Lisa (2009-03-01). "Obesity, stigma and public health planning". Health Promotion International. 24 (1): 88–93. doi:10.1093/heapro/dan041. ISSN 0957-4824. PMID 19131400. 
  21. ^ a b c d e f g h i Janssen, Ian; Craig, Wendy M.; Boyce, William F.; Pickett, William (2004-05-01). "Associations between overweight and obesity with bullying behaviors in school-aged children". Pediatrics. 113 (5): 1187–1194. doi:10.1542/peds.113.5.1187. ISSN 1098-4275. PMID 15121928. 
  22. ^ a b c d e Puhl, Rebecca M.; Latner, Janet D. "Stigma, obesity, and the health of the nation's children". Psychological Bulletin. 133 (4): 557–580. doi:10.1037/0033-2909.133.4.557. PMID 17592956. 
  23. ^ Davison, Kirsten Krahnstoever; Birch, Leann Lipps. "Processes linking weight status and self-concept among girls from ages 5 to 7 years". Developmental Psychology. 38 (5): 735–748. doi:10.1037/0012-1649.38.5.735. PMC 2530914Freely accessible. 
  24. ^ "Associations of weight-based teasing and emotional well-being among adolescents". Archives of Pediatrics and Adolescent Medicine. 157. 
  25. ^ Russell-Mayhew, Shelly; McVey, Gail; Bardick, Angela; Ireland, Alana (2012-06-24). "Mental Health, Wellness, and Childhood Overweight/Obesity". Journal of Obesity. 2012: 1–9. doi:10.1155/2012/281801. ISSN 2090-0708. 
  26. ^ Keery, Helene; Boutelle, Kerri; Berg, Patricia van den; Thompson, J. Kevin. "The impact of appearance-related teasing by family members". Journal of Adolescent Health. 37 (2): 120–127. doi:10.1016/j.jadohealth.2004.08.015. 
  27. ^ "Weight-teasing among adolescents: Correlations with weight status and disordered eating behaviors". International Journal of Obesity. 26. doi:10.1038/sj.ijo.0801853. 
  28. ^ Haines, Jess; Neumark-Sztainer, Dianne; Eisenberg, Marla E.; Hannan, Peter J. (2006-02-01). "Weight Teasing and Disordered Eating Behaviors in Adolescents: Longitudinal Findings From Project EAT (Eating Among Teens)". Pediatrics. 117 (2): e209–e215. doi:10.1542/peds.2005-1242. ISSN 0031-4005. PMID 16452330. 
  29. ^ Kaltiala-Heino, R.; Rissanen, A.; Rimpela, M.; Rantanen, P. (1999-07-01). "Bulimia and bulimic behaviour in middle adolescence: more common than thought?". Acta Psychiatrica Scandinavica. 100 (1): 33–39. doi:10.1111/j.1600-0447.1999.tb10911.x. ISSN 1600-0447. 
  30. ^ Farhat, Tilda; Iannotti, Ronald J.; Simons-Morton, Bruce G. "Overweight, Obesity, Youth, and Health-Risk Behaviors". American Journal of Preventive Medicine. 38 (3): 258–267. doi:10.1016/j.amepre.2009.10.038. PMC 2826832Freely accessible. 
  31. ^ a b Schafer, Markus H.; Ferraro, Kenneth F. (2011-03-01). "The Stigma of Obesity Does Perceived Weight Discrimination Affect Identity and Physical Health?". Social Psychology Quarterly. 74 (1): 76–97. doi:10.1177/0190272511398197. ISSN 0190-2725. 
  32. ^ a b c d Hunger, Jeffrey M.; Major, Brenda; Blodorn, Alison; Miller, Carol T. (2015-06-01). "Weighed Down by Stigma: How Weight-Based Social Identity Threat Contributes to Weight Gain and Poor Health". Social and Personality Psychology Compass. 9 (6): 255–268. doi:10.1111/spc3.12172. ISSN 1751-9004. 
  33. ^ Bombak, Andrea E. (2015-01-01). "Obese persons' physical activity experiences and motivations across weight changes: a qualitative exploratory study". BMC Public Health. 15: 1129. doi:10.1186/s12889-015-2456-0. ISSN 1471-2458. PMC 4650293Freely accessible. PMID 26577260. 
  34. ^ a b c d Puhl, Rebecca M.; King, Kelly M. "Weight discrimination and bullying". Best Practice & Research Clinical Endocrinology & Metabolism. 27 (2): 117–127. doi:10.1016/j.beem.2012.12.002. 
  35. ^ Jackson, Sarah E.; Beeken, Rebecca J.; Wardle, Jane (2015-05-01). "Obesity, perceived weight discrimination, and psychological well-being in older adults in England". Obesity. 23 (5): 1105–1111. doi:10.1002/oby.21052. ISSN 1930-739X. 
  36. ^ a b Phelan, Sean M.; Burgess, Diana J.; Puhl, Rebecca; Dyrbye, Liselotte N.; Dovidio, John F.; Yeazel, Mark; Ridgeway, Jennifer L.; Nelson, David; Perry, Sylvia (2015-07-15). "The Adverse Effect of Weight Stigma on the Well-Being of Medical Students with Overweight or Obesity: Findings from a National Survey". Journal of General Internal Medicine. 30 (9): 1251–1258. doi:10.1007/s11606-015-3266-x. ISSN 0884-8734. 
  37. ^ Sikorski, Claudia; Luppa, Melanie; Luck, Tobias; Riedel-Heller, Steffi G. (2015-02-01). "Weight stigma "gets under the skin"—evidence for an adapted psychological mediation framework—a systematic review". Obesity. 23 (2): 266–276. doi:10.1002/oby.20952. ISSN 1930-739X. 
  38. ^ a b c d e f g Papadopoulos, Stephanie; Brennan, Leah (2015-09-01). "Correlates of weight stigma in adults with overweight and obesity: A systematic literature review". Obesity. 23 (9): 1743–1760. doi:10.1002/oby.21187. ISSN 1930-739X. 
  39. ^ a b c Puhl, Rebecca; Suh, Young (2015-02-05). "Stigma and Eating and Weight Disorders". Current Psychiatry Reports. 17 (3): 1–10. doi:10.1007/s11920-015-0552-6. ISSN 1523-3812. 
  40. ^ Puhl, Rebecca; Brownell, Kelly D. (2001-12-01). "Bias, Discrimination, and Obesity". Obesity Research. 9 (12): 788–805. doi:10.1038/oby.2001.108. ISSN 1550-8528. PMID 11743063. 
  41. ^ Stunkard, Albert J.; Sorensen, Thorkild I.A. (1993-09-30). "Obesity and Socioeconomic Status – A Complex Relation". New England Journal of Medicine. 329 (14): 1036–1037. doi:10.1056/NEJM199309303291411. ISSN 0028-4793. PMID 8366906. 
  42. ^ Tehran, Elizabeth E. (2005). Legal theory on weight discrimination. In K. Brownell, R. Puhl, M. Schwartz, & L. Rudd (Eds.), Weight bias: nature, consequences, and remedies (pp. 195–211). New York, NY.
  43. ^ Puhl, Rebecca M.; Heuer, Chelsea A. (2010-06-01). "Obesity Stigma: Important Considerations for Public Health". American Journal of Public Health. 100 (6): 1019–1028. doi:10.2105/AJPH.2009.159491. ISSN 0090-0036. PMC 2866597Freely accessible. PMID 20075322.