Addressing Weight Stigma and Weight-Based Discrimination in Children: Preparing Pediatricians to Meet the Challenge

Overweight and obesity affect more than 17% of children worldwide.¹ In the European region, 1 in 3 children between the ages of 6 and 9 years currently has overweight or obesity,² whereas in the US, childhood obesity rates have tripled over the past 3 decades and currently about 1 in 3 children is has overweight or obesity.³ The prevalence of obesity in the population aged 2–19 years residing in the US during 2017–2020 was 19.7%, affecting about 14.7 million children and adolescents.⁴ Children and adolescents living with overweight and obesity often are stigmatized by peers and viewed negatively because of their distinguishing characteristic, which is considered by many a social disadvantage.¹ Weight stigma has important social implications and can hamper the success of antiobesity treatments. Children and adolescents are particularly vulnerable to the negative consequences of weight stigma in their families and communities. Discrimination against children based on weight is equal to that of other types of stigma, including that based on race, religion, or physical disability.⁵ This commentary, prepared by a working group of international experts in the field convened by the European Pediatric Association, Union of National Pediatric Societies and Associations, aims to raise awareness of weight stigma and its negative effects on children and adolescents and to emphasize the importance for pediatricians to be adequately trained to address this challenge in their practice.

Definition of Weight and Obesity Stigma

Stigma defines a negative attitude or discrimination against individuals based on a distinguishing characteristic of various kinds, including sexuality, race, religion, culture, and health condition.⁶ Misconceptions and prejudice can exacerbate the suffering and distress of individuals with many health conditions and generate disease stigma, as in the case of obesity. Specifically, weight stigma refers to discriminatory actions directed at individuals because of their weight, size, and look. Prejudices that generate weight stigma are frequently supported by negative ideologies associated with obesity, which may include laziness, lack of willpower, lack of moral character, poor hygiene, low intelligence, and lack of attractiveness.⁶

Weight Stigma and Identity Threat in Children

Weight-related prejudices, stereotypes, and preconceptions induce a threat to social identity in children and adolescents who experience stigma.^7–9 Victimized individuals often are ridiculed or bullied by peers or regarded unfairly by people, frequently due to the common perception that weight stigma is justifiable and motivates children to adopt healthier behaviors. Children living with obesity who experience discrimination related to their weight often show poor psychological and emotional health.^7–9 Existing evidence suggests that weight stigma causes long-term negative effects and severe implications for the physical and mental health of children and adolescents, which may continue into adulthood.^7–9

Internalized Weight Stigma

Literature on the processes that lead to the internalization of weight stigma by children and adolescents is scarce.¹⁰ Experiencing weight stigma does not necessarily lead to its internalization.¹¹ However, several studies report the negative effects of internalized weight stigma on mental health in particularly fragile subjects such as children and adolescents.¹² These subjects may undergo a process of self-stigmatization similar to that observed in mental illness and thus suffer a form of self-devaluation resulting from weight stigma.¹² Individuals experiencing internalization processes accept and agree to a different extent with the external description of their weight condition and apply these connotations to themselves. This process, described as internalization of weight bias,¹³ can further increase the negative consequences of stigma and, in some circumstances, is considered more important than the experience of stigma or weight status alone.¹² Increased negative health outcomes are often associated with the early onset of mental health problems.¹²

Weight Stigma in Different Contexts and Its Many Consequences

Weight stigma is prevalent among youth, the media, schools, workplaces, and even families and healthcare facilities. Victimization, mockery, and bullying characterize the practice of weight stigma by young people.¹⁴ Beginning in kindergarten, children may apply negative stereotypes to their classmates with larger builds. Increasing reports show that educators and parents also exercise weight stigma through weight-based victimization of youth. Teachers and parents hold lower expectations in various areas, including sports, social relationships, and academic abilities, for children and adolescents living with overweight and obesity, who are considered disadvantaged compared with children of normal weight.¹⁴ An additional source of weight stigma is television and other media that young people commonly watch for several hours a day, where entertainment shows and movies often use easy stereotypes such as characters with larger builds who are portrayed negatively and as targets of humor or ridicule to increase viewership. The use of social networks has facilitated the rise of new forms of victimization such as cyberbullying, which can spread through the network with extreme ease and in a severely invasive manner. Cyberbullying often uses weight stigmatization as a strong form of discrimination and offense.

Weight stigmatization also can occur in healthcare settings, wherein healthcare professionals often express various forms of weight stigma toward children with obesity. The use of terms and definitions that are perceived as undesirable, stigmatizing, or blaming by children and adolescents, such as fat, obese, or extremely obese, are often the cause of a lack of motivation. These attitudes can affect patients with obesity who may suffer from stress, showing avoidance of treatment and worse outcomes due to distrust of doctors and low expectations of treatment. Finally, weight stigma causes various psychological, emotional, and social consequences, impacting the physical health of children and adolescents,¹⁵ including negative outcomes that may reinforce unhealthy behaviors, which promote obesity and weight gain^16,17 (Table I; available at www.jpeds.com).

Table I.

Psychological, physical, and social effects of weight stigmatization in children and adolescents

• Emotional and psychological consequences

Weight-based stigmatizing experiences may trigger emotional and psychological effects, including low self-esteem, increased vulnerability to mental diseases, depression, anxiety, drug and other substance use, and poor body image. Self-harm and suicidal behaviors are greater in children and adolescents victimized about their weight compared with peers of the same age and weight who have not been target of weight stigmatization

• Social isolation and poor academic outcomes

Weight-based victimization induces social isolation and is the cause of poor academic outcomes. Weight-based discrimination in school influences the relationships between students and generates a progressive decline in school performance compared with previous years. Often children and adolescents disengage from their academic duties and school environment.

• Unhealthy eating behaviors

Weight-based harassment worsens unhealthy eating behaviors.

• Reduced physical activity

Exercise and physical activities are severely impacted by weight-based stigmatization. Socializing physical activities are significantly reduced, further influencing the relationships with peers and minimizing the motivations to follow antiobesity treatments.

• Worsening obesity

Being victims of weight-based stigma may often demotivate the victims, who perceive as useless their efforts to improve their condition. Weight stigma and discrimination increase the risk of developing and continuing to have obesity over time.

Addressing Weight Stigma by Pediatricians and Educators

Pediatricians play an important role in protecting children from the risks of adverse events.¹⁸ They must engage in strategies that address the sensitive issue of weight to promote resilience and help children and their families cope with stigma (Table II; available at www.jpeds.com). Countering stigma in general and weight stigma in particular should play a central role in educational programs.¹⁹ Appropriate academic training and continuing education programs committed to countering stigma should be dedicated to all professionals considered central to these strategies, including pediatricians, other health professionals, and educators. Efforts should be made to involve public and private organizations, including professional, scientific and community associations²⁰ in countering “weight stigma” and learning how to deal with this form of discrimination and its consequences, while developing healthy attitudes and positive relationships in families (Table III; available at www.jpeds.com).

Table II.

Recommendations for the contrast of weight stigma to be shared with public and private institutions involved in childhood care

• Acknowledge obesity as a chronic disease.

• Provide training for health care professionals on obesity and weight stigma.

• Require all accredited health care facilities to address obesity with trained professionals and adequate equipment, to facilitate access to care and sustainable change toward healthier lifestyles.

• Avoid stigmatizing and/or weight-centered advertising campaigns.

• Spread the antistigma culture in all areas: health, education, politics, and media. Eliminate negative language, words, images when referring to children and adolescents with obesity and their families.

• Carefully evaluate reports, interviews, and articles published regarding the choice of words and images, to promote a culture which does not promote stigma in the media.

• Fund research on the treatment of obesity and stigma proportionally to the prevalence and impact they have on health.

Support “strong” policies to ban stigma on weight as a violation of the right to physical and mental health.

III.

Tackling weight stigma in children:recommendations for pediatricians and health professionals

• Ask for permission to discuss the child’s/adolescent’s weight before addressing the topic.

• Respectfully evaluate the weight status of each child/adolescent, with the body mass index z score, and communicate the diagnosis to children and parents in a nonjudgmental way. Help the patient and family to understand the complex nature of obesity and the responsibility of the current obesogenic environment.

• Provide a comprehensive evaluation of each child/adolescent on a physical and psychological level.

• Investigate with adequate language about previous episodes of ridicule, discrimination, internalization of stigma (possible questions: “Do you think that your weight influences the evaluation you have of yourself?”; “How do you see yourself?”; “What do you think of yourself?”).

• Contextualize the official recommendations for the care of obesity to the family and the child/adolescent and ask for their participation in making a personalized and sustainable care plan; arrange for integration with other professionals in specific cases. Explain the changes and avoid unjustified simplifications (eg, the presumption that “small, easy daily changes in diet and physical activity are enough”).

• Periodically provide a global assessment of the child/adolescent, to empathically support strategies to improve behavior and well-being. Don’t assume that if weight hasn’t changed, neither have behaviors.

• Help parents become aware of weight stigma and to investigate any incidents of ridicule, discrimination, bullying, and cyberbullying at school or in the family itself, and to address them appropriately.

• Refer children/adolescents with severe or complicated obesity who do not respond to treatment to second-level centers, accompanying them and taking care of their transition to the general practitioner.

Conclusions

Childhood and adolescence are periods of life in which social relationships are forged, and the experience of discrimination by weight stigma can be a damaging experience, particularly painful if experienced at a time when peer rejection is keenly felt.^8,9 Pediatricians and pediatric health care providers can play an important role in addressing any form of discrimination, including child and adolescent stigma, by raising awareness that weight stigma is a form of discrimination and its related stereotypes do not reduce obesity or improve healthy behaviors.¹⁴