One third of U.S. children, aged 2–19 years, have overweight or obesity. In economically challenged communities, this number may double. One in five children is classified with obesity, making it the most common chronic condition in this population (Skinner, Ravanbakht, Skelton, Perrin, & Armstrong, 2018).
In addition to the burden of having a serious disease, these children are likely to be burdened by stigma and discrimination. The most common manifestations of stigma for youth with overweight or obesity are bullying, teasing, and victimization. Discrimination may come at them from all fronts—peers, educators, the media, parents, and healthcare providers—with deleterious effects on their current and future physical and mental health, and quality of life (Pont, Puhl, Cook, Slusser, & Section on Obesity, Obesity Society, 2017).
WEIGHT STIGMA IN SCHOOLS
Weight stigma and bullying are a significant problem in school settings. In a 2011 study conducted by the National Education Association, teachers named weight-based bullying as the most problematic form of bullying in the classroom. Additional research recognized that students, educators, and parents all view weight-based bullying as a serious problem, one that surpasses bullying that occurs because of sex, sexual orientation, or disability (Bradshaw, Waasdorp, O’Brennan, & Gulemetova, 2013). Bullying may be physical, relational, social, verbal, or cyber (Kingsford, 2014).
In addition to peer bullying, these children may experience weight stigma from their educators. This typically manifests as teachers having lower expectations regarding physical, social, and academic abilities and making more negative assessments of academic performance than they would for a child without overweight or obesity (Peterson, Puhl, & Luedicke, 2012).
WEIGHT STIGMA IN THE MEDIA
Media portrayals of children carrying excess weight are prevalent and damaging. A study that analyzed recent children’s movies found that 70% of them contained weight-related stigmatizing content, with 90% of the stigmatizing content being directed at characters with obesity (Throop et al., 2014). Children with excess weight are frequently characterized as aggressive, unpopular, evil, lazy, unintelligent, and unhealthy and are often the target of ridicule, whereas slimmer children are cast as kind, popular, and attractive (Pont et al., 2017).
In addition to weight stigmatizing messages, these movies promoted unhealthy food and depicted healthy food choices such as fruits and vegetables in an unfavorable manner, presenting an impossible dilemma for the children who view them (Howard et al., 2017). When one considers the amount of time children spend watching media, this conflict is deeply problematic.
WEIGHT STIGMA FROM PARENTS AND FAMILY
Family members are the most prevalent source of interpersonal weight stigmatizing incidents for children with overweight and obesity. In a survey of women with obesity, 53% reported that they experienced weight stigma from their mothers, whereas 44% reported it from their fathers (Puhl & Brownell, 2006). This stigma may include teasing and bullying (Puhl, Peterson, & Luedicke, 2013). The negative emotional consequences of parental stigma are long lasting and continue through adulthood (Puhl, Moss-Racusin, Schwartz, & Brownell, 2008).
WEIGHT STIGMA IN HEALTHCARE
People with obesity report frequent stigmatization in healthcare settings (Phelan et al., 2015). Weight bias is common among physicians, nurses, dietitians, psychologists, and medical trainees, many of whom report prejudice toward this population of patients (Puhl & Heuer, 2010). This bias manifests as less time spent in conversations, reluctance to perform preventative health screenings, ascribing more severe mental health pathology, and providing a worse prognosis than to patients without excess weight (Puhl & Heuer, 2010).
Most healthcare providers do not feel comfortable or competent discussing weight issues. They receive little, if any, education about weight conditions in their formal preparatory programs and have limited access to professional continuing education. As a result, they are not able to discuss weight conditions with their patients with knowledge and sensitivity. This leads to missed or canceled appointments, including screenings and treatment (Puhl & Heuer, 2010).
EFFECTS OF STIGMA AND BULLYING
Children who are stigmatized and bullied internalize the negative judgments and may turn them against themselves. Those with internalized stigma have higher rates of metabolic disease and mortality. Weight-based teasing harms mental health and self-esteem, leads to eating to cope with emotions, and increases the chance of weight gain and obesity in adulthood (Puhl et al., 2017).
When caring for children with weight issues, watch for signs of bullying. Common manifestations are resistance to going to school or riding the bus, dropping grades, withdrawal from social activities, acting out, or somatic complaints such as headache, stomachache, and difficulty sleeping. Many children do not tell adults about what is happening out of fear of retaliation from the bullies or because they feel ashamed about their weight and being bullied (Kingsford, 2014).
Given the numerous physical and mental health consequences and compromised quality of life that result from weight bias and stigma, it is imperative that pediatric healthcare professionals are knowledgeable and sensitive about weight conditions. Below are suggestions that can be incorporated into any pediatric setting.
- Seek education about childhood obesity. Review the Obesity Medicine Association’s Pediatric Algorithm (https://obesitymedicine.org/childhood-obesity/), which outlines the science of pediatric obesity assessment and treatment. Another resource is the AAP Institute for Healthy Childhood Weight (https://ihcw.aap.org/Pages/default.aspx).
- Learn more about weight stigma and children. Familiarize yourself with the AAP policy statement, Stigma Experienced by Children and Adolescents With Obesity (http://pediatrics.aappublications.org/content/early/2017/11/16/peds.2017-3034), that was published in collaboration with The Obesity Society. The Rudd Center for Food Policy and Obesity Web site (http://www.uconnruddcenter.org) also provides resources about pediatric weight and health.
- Acknowledge and explore your own bias about weight and obesity. We all have bias, so it is nothing to be ashamed of. Awareness of, and compassion for, your own bias will make it less likely that you will inadvertently stigmatize children and families affected by weight issues.
- Recognize that blame and shame are counterproductive. Many believe that blame and shame will motivate, but they actually result in less motivation, less healthful choices, and weight gain. Children who have experienced weight stigma are more likely to gain weight and have obesity as adults (Puhl & Heurer, 2010 ; Rand et al., 2017).
- Create open, safe relationships with children and families affected by obesity. Let them know that they can talk to you without fear of judgment or ridicule. You may be one of a few who can talk to them in a manner that is productive and sensitive.
- Learn how to talk to children and families affected by obesity. Ask permission to talk about weight. Inquiries such as “Would it be okay if we talk about your weight?” convey respect and sensitivity. Familiarize yourself with People First Language for Obesity (http://www.obesityaction.org/weight-bias-and-stigma/people-first-language-for-obesity), which emphasizes the importance of putting the person before the disease. Use terms such as “children affected by obesity” or “children with obesity and excess weight” rather than “obese,” “extremely obese,” or “fat.” Refrain from using stigmatizing terms when interacting with a child as well as with parents and colleagues, particularly if the child is present. The publication Pediatricians: How To Talk To Parents About Obesity (http://www.uconnruddcenter.org/files/Pdfs/Pediatricians_HowTalkToParents.pdf) provides guidelines for conversations with parents.
- Inquire about bullying. Ask questions such as “When kids carry extra weight, they might be bullied by others. Has that ever happened to you?” If you learn that a child is being bullied, emphasize that bullying is not okay. If bullying is happening outside the home, ask if they have talked to their parents. If it is happening at home, ask for permission to discuss their experiences with their parents, so that you can guide them in more effective strategies.
- Teach parents how to talk skillfully to their kids about weight. Empower them to focus on positives, and ask questions about how the child experiences weight. Offer suggestions about how to broach the topic, such as “Would it be okay to talk about your weight?”, and then respect the child’s answer. Focus on eliciting the child’s thoughts, feelings, and struggles about weight, rather than lecturing.
- Model skillful communication with your colleagues. Share your knowledge about childhood obesity and the importance of addressing bias and stigma. Respectfully correct stigmatizing comments and terms.
- Provide resources for children and families. Locate providers and programs that offer science-based medical treatment for weight conditions. Those that focus on health and involve the family are shown to be most effective.
When one considers the impact that childhood weight conditions have on children, families, and society, both now and in the future, it is easy to recognize the importance of reducing weight stigma and bias for all those who are affected.
Informed, sustained efforts will shift the focus from one of blame and shame to one that improves health.
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