The Impact of Stigma on the Child with Obesity: Implications for Social Work Practice and Research
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- Lawrence, S.A. Child Adolesc Soc Work J (2010) 27: 309. doi:10.1007/s10560-010-0208-7
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Childhood obesity has greatly increased in the past 20 years and is highly stigmatized in today’s society. The effectiveness of obesity prevention efforts is threatened by the systemic impact of stigma that surrounds obesity. As childhood obesity increases so to does the responsibility of social workers to implement multi level interventions that not only assist children who are experiencing stigmatization, but are aimed at reducing stigmatization. This article reviews the origins of overweight stigmatization and the psychosocial influences of such stigmatization. The implications for social work practice and research from a systemic approach are addressed.
Prior to 1980 the percentage of overweight and obese children was relatively small; 6.5% of children ages 6–11 were overweight or obese and 5% of children ages 12–19 were overweight or obese (Eliadis 2006). By 2004, this percentage significantly increased to 18.8% of and 17.4% respectively (CDC 2009). Alarmingly, an additional 31% of children under the age of 18 are at risk of being overweight (Hedley et al. 2004).
With the increase in obesity in recent years, it would stand to reason that the degree of discrimination against and stigmatization of children who are overweight would decrease. This however, is not the case; the bias against obese children has grown stronger. Approximately 50% of obese boys and 58% of obese girls report experiencing significant problems with their peers (Warschburger 2005). Victimization among obese youth is up to twice as high as rates reported among nonobese adolescents (Hayden-Wade et al. 2005). Because of the drastically increasing rates of childhood obesity, stigmatization against obese children has the potential to negatively affect greater numbers of children than ever before (Latner et al. 2007). Research has indicated that discriminatory and prejudicial attitudes about obesity emerge by the age of three (Cramer and Steinwert 1998; Warschburger 2005). Stigma encountered by overweight and obese children includes verbal teasing, physical bullying, and relational victimization (exclusion, being the target of rumors) (Puhl and Latner 2007).
This article reviews the origins of overweight stigmatization and the psychological, social, academic and physical consequences of this stigmatization. The implications for social work practice and research from a person-in-environment perspective, focusing on micro, mezzo, macro level systems are also addressed.
Origins of Overweight/Obesity Stigma
The origins of weight bias or stigmatization of overweight children are not well researched; however the scant literature(Anesbury and Tiggemann 2000; Bell and Morgan 2000) does suggest that multiple systems, including the family, teachers peers, media and teachers and the community interact with each other to contribute to this phenomenon.
Children may be strongly influenced by their parents who may unknowingly model biased beliefs (Latner et al. 2007). While there has been a limited number of studies surrounding the role of parental biases in the formation of childhood biases, the findings have been consistent and discouraging (Puhl and Latner 2007). Davison and Birch (2004) examined stereotypes among 9 year old girls and their parents and found that girls were more likely to display negative stereotypes against overweight individuals if their parents emphasized the importance of being thin and weight loss. These stereotypes were found regardless of the whether the parents were overweight or of average size. In a population based study, Neumark-Sztainer et al. (2002) found that 47% of very overweight girls and 34% of very overweight boys reported being teased about their weight by family members.
Biased attitudes among parents may stem from stigma perceived by parents (Puhl and Latner 2007). In other words, a parent may develop negative attitudes towards their overweight child because they feel blamed. A study of 67 children and their parents found that parents reported that they felt blamed and criticized for their child’s overweight (Pierce and Wardle 1997). Girls whose interactions with their parents focused on body shape and weight loss were more likely to endorse overweight stereotypes.
Exposure to media may be another contributor to the development of weight stigmatization (Latner et al. 2007). A historical view of the media’s portrayal of the ideal body size and shape demonstrates change over the past century (Lawrie et al. 2006). The ideal shape for women has changed from curvaceous to lean and slim to align with current fashion trends (Katzmarzyk and Davis 2001). The ideal body shape for men has changed from larger to a more muscular, physically fit appearance (McCabe and Ricciardelli 2004). Popular media portrays thinness as leading to social rewards such as happiness and financial success, while overweight is portrayed as leading to undesirable consequences. A study conducted in 2003 by Greenberg and colleagues analyzed characters in 60 television shows. Obese people were underrepresented and thin people were over-represented. Heavier characters had fewer romantic interactions and overweight males were less likely to be employed. Larger females were more likely to be made fun of then thinner female characters (Greenberg et al. 2003).
A 2007 study examined the relationship between exposure to three distinct types of media: TV, videogames and magazines, and stigmatizing attitudes toward obese children (Latner et al. 2007). The researchers found that total and weekend media use and videogame playing time were associated with stigmatization. Greater dislike of obese children when compared to their peers was uniquely predicted by magazine reading time. In boys, obesity stigmatization was associated with TV viewing time. This suggests that the children may receive stigmatizing messages from videogames and magazines, and that boys may be especially vulnerable to the stigmatizing messages presented on TV (Latner et al. 2007). Magazine exposure stands out as uniquely associated with devaluation of overweight/obese male and females. Magazines may be particularly harmful because their pictures are often airbrushed; consequently their images appear as being more flawless than those on TV (Latner et al. 2007). Exposure to media content promoting the ideal weight and shape is associated with body dissatisfaction and increased risk of eating disorders (Cusumano and Thompson 2001). The belief that what is beautiful is good may lead children to devalue their own body weight while at the same time teaching them to devalue others who do not fit into the ideal body type.
Medical Professional Influence
Weight bias in medical care settings and amongst health professionals is a major concern (Schwartz et al. 2003). Research has indicated that obese individuals are discriminated against by health care professionals and often receive shorter examinations and are more often ascribed negative attributes (Hebl et al. 2003). Doctors, more than family, strangers and employers were identified as being the primary source of bias towards obese women (Puhl and Latner 2007). Their negative attitudes towards obese people may be related to the societal belief that obese individuals are self indulgent lazy and lack self-discipline (Paul and Townsend 1995). While there is no literature addressing weight bias of medical professionals towards children, research has indicated that parents often feel that they are to blame for their child’s obesity. This feeling of blame may be implied or even stated by the medical professionals. The financial impact of obesity in terms of health care costs is well known. This cost may be a result of a vicious cycle perpetuated by medical professionals. Obese patients are reluctant to seek health care because of discrimination by the healthcare professional, thus increasing the likelihood of medical problems, resulting in the lack of early detection of disease (Schwartz et al. 2003).
Consequences of Stigmatization
The potential physiological consequences of obesity in children including hypertension, diabetes, cardiac risk factors and sleep apnea, are well documented, (Cook et al. 2003; Freedman et al. 2007; Weiss et al. 2000). Stigmatization of overweight/obese children can have devastating biopsychosocial consequences such as psychological problems (decreased self esteem, depression), academic problems, interpersonal difficulties and physical health problems (binge eating, purging, lack of physical activity).
Children who are obese report being teased three times more often than average weight children (Neumark-Sztainer et al. 2002; Warschburger 2005). Ackard et al. (2003) found that nearly all obese girls interviewed reported being treated “differently” and being rejected because of their weight. It was reported that not only were the girls’ peers making hurtful comments, but family members and strangers were as well. This teasing likely acts as a mediating variable between obesity and the psychological consequences of stigmatization.
While research surrounding the relationship between self-esteem and obesity is weak in the immediate sense, prospective studies examining the development of low self-esteem typically show that being overweight in childhood predicts future low self-esteem (Hesketh et al. 2004; Strauss 2000; Tiggemann 2005). It is likely that stigma-related variables such as weight based teasing and criticism from parents (Davison and Birch 2004) mediate the relationship between obesity and self-esteem (Puhl and Latner 2007). A study of 9–11 year olds indicated that those obese children who were most vulnerable to low self-esteem were those who believed that they were responsible for being overweight. Those with a more positive self-esteem attributed their weight to causes that were beyond their control (Pierce and Wardle 1997).
The literature surrounding the relationship between depression and obesity is conflicting and unclear. Prospective studies of adolescent girls found that obesity did not predict depression at follow-up, while some studies found that depression in childhood predicted higher weight in adulthood (Anderson et al. 2006; Goodman and Whitaker 2002). Similar to the relationship between obesity and self-esteem, research indicates that weight based teasing may mediate the relationship between depression and obesity in adolescents (Eisenberg et al. 2003; Keery et al. 2005). The same was found regarding the relationship between body dissatisfaction, actual body weight does not affect one’s body image; the effect is moderated by teasing (Keery et al. 2005).
Research has reported that children who are obese have lower math and reading achievement than non overweight/obese children (Datar et al. 2004; Dietz 1997; Gortmaker et al. 1993). In some of the studies, after controlling for SES and other demographic variables, the differences were no longer significant (Datar et al. 2004). The difference between the two groups may be related to socioeconomic factors, indicating that obesity is likely not the cause but a marker. The combination of obesity and lower socioeconomic status has the potential to further increase stigmatization (Datar et al. 2004; Pyle et al. 2006). Obese children often consider themselves to be poor students (Falkner et al. 2001). This belief may be the result of perceived lower academic achievement of obese children by teachers and social workers not as a result of actual academic ability.
Research has consistently found that when children are asked about their friendship preferences they consistently preferred to befriend peers who are of average weight (Crandall et al. 2001; Penny and Haddock 2006; Richardson et al. 1961). A classic study of the stigmatization of overweight children was conducted in 1961 by Richardson and colleagues. The researchers instructed 640 children ages 10–11 to rank six pictures in order of whom they would most like to be friends with. Four of the pictures featured children with a disability, one of an average weight child with no disabilities and one of an overweight child. The overweight child was ranked last of the six pictures and was rated as being the least likable (Richardson et al. 1961). This study was replicated in 2003 by Latner and Stunkard with children of the same ages. As in the original study, the overweight child was rated being the least liked with the distance between the average rankings of the highest and lowest ranked pictures increasing over 40% since the original 1961 study (Latner and Stunkard 2003).
The stigma of obesity is pervasive and has a far reaching impact (Penny and Haddock 2006). Studies have shown that when a non-stigmatized individual has a relationship (or perceived relationship) with an individual who is stigmatized, they too can become the victim of stigmatization (Gallagher et al. 2003; Hebl and Mannix 2003). A recent study has found that this proximity stigmatization is evident in children as young as 5 years of age (Penny and Haddock 2006). A study by Powlishta et al. (1994) found that the proximity effect seems to decrease with age. One interpretation of this finding is that children who are older are less likely to be overweight or obesity prejudiced. Another explanation is that older children realize that it is wrong to discriminate and are therefore less likely to verbalize or otherwise indicate their prejudices (Penny and Haddock 2006). While there does seem to be a decrease of stigmatization with age, research has indicated that adults who are seated next to an obese individual while waiting for an interview, were less likely to be hired that those who were seated next to a thinner individual. This indicates that the ‘guilty by association’ is carried into adulthood.
Overweight adolescents are more likely than average weight youths to engage in negative eating behaviors such as binge eating or chronic dieting (Neumark-Sztainer et al. 1997). In addition, compared with non overweight girls, overweight girls are twice as likely to report vomiting and unhealthy use of diet pills and laxatives (Boutelle et al. 2002). Overweight girls and boys who experience frequent weight teasing are more likely to engage in unhealthy weight control behaviors or binge eating then overweight adolescents who were not teased. This relationship remained even after BMI and SES were controlled for. Consistent with many of the consequences of obesity, these findings suggest that the teasing mediates these negative behaviors, the negative behaviors are a function of the teasing, not the weight (Neumark-Sztainer et al. 2002).
Children who are the targets of weight criticism not only develop negative attitudes towards sports but also report reduced physical activity levels (Faith et al. 2002), which may lead to more weight gain, further exacerbating the stigmatization. Engagement in physical activity is important for children not only in terms of physiological protection such as lower body weight, blood pressure and bone strength but also on psychological factors such as self-concept and performance in school (Faith et al. 2002).
Implications for Social Work Practice and Research
While the research and treatment of obesity and its consequences has been approached from an interdisciplinary manner, social work has not played a large role in addressing this issue. There is an enormous opportunity for social workers to join the fight to reduce stigma from a systemic approach. Despite the well researched consequences of weight bias and peer victimization on the psychosocial functioning and health behaviors of obese children, only two known intervention studies aimed at reducing stigmatization have been conducted in this area (Anesbury and Tiggemann 2000; Bell and Morgan 2000). Both of the interventions focused on the child, rather than taking a systemic approach to the problem. The interventions emphasized the amount of controllability children assigned to obesity. The interventions consisted of education surrounding the medical causes of obesity (Anesbury and Tiggemann 2000; Bell and Morgan 2000). Bell and Morgan (2000) found a minimal positive effect on attitudes and behaviors while Anesbury and Tiggeman (2000) found that the beliefs about the cause of obesity had changed, their stereotyping behaviors remained the same. Clearly, obesity among children is a serious health issue. At the same time, feeling stigmatized due to an over-weight appearance also has mental health and social consequences. Social workers, as change agents, are in a unique position to address both strategies for behavior changes that will reduce obesity as well as approaches for addressing the negative consequences of stigmatization due to appearance at the micro, mezzo and macro levels. By targeting overweight children and their peers, perhaps in a psycho-educational group setting, social workers can be instrumental in reducing childhood obesity as well as moderating the negative impact of peer pressure on children.
Micro Level Implications
There is no consensus in terms of recommendations for the evaluation of mental health in overweight/obese children and adolescents (McClanahan et al. 2008). Asking the correct questions in “objective, non accusatory language” (p. 381), will aid in establishing a basis of trust between the client and the mental health provider. This is critical to long term successful weight management (McClanahan et al. 2008) and ultimately the reduction of stigma. Addressing mental health by comprehensive assessment is of critical importance in improving the outcome of obesity related issues in adolescents (McClanahan et al. 2008). Social workers focus on a systemic approach, taking into account one of the fundamental principles of social work: A strengths perspective. Self-efficacy (an individual’s confidence in their ability to perform a task or behavior) plays a key role in terms of the strengths perspective. The social worker can not only provide support to the victimized child but also help them to understand that they have control over their behaviors and can help them increase their self-efficacy and self-esteem by focusing on, and increasing their inherent strengths and abilities. Body related concerns are often reported as being a barrier to participating in physical activity by overweight students. School social workers should collaborate with physical education teachers in creating fun, age appropriate, health promoting interventions that encourage physical activities and minimize body consciousness (Zabinski et al. 2003) while focusing on short term, attainable goals in order to increase the chances of success and maximize self-efficacy.
Mezzo Level Implications
The peer group has been identified as being as the primary perpetrator of weight bias and peer victimization, suggesting that victimization is socially sanctioned (Hayden-Wade et al. 2005). Interventions focusing on reducing a child’s belief that obesity is something that is not within the child’s control have been unsuccessful in reducing stereotypes (Anesbury and Tiggemann 2000; Bell and Morgan 2000). Among older children, explaining that obesity is a physical condition that is out of the child’s control actually decreased their peers’ willingness to engage in activities with the child. Interventions therefore need to be focused at the at the peer level. The limited success of these interventions in this area may be due to targeting of children rather than their entire social network.
Weight bias and victimization of obese children is a socialized construct that is reinforced by many different sources, including parents, peers, school officials, and society at large (Gray et al. 2009). For interventions to be effective in reducing victimization of obese children, researchers and practitioners need to focus on interventions based on an ecological framework targeting peers, parents, school officials, and society. School-wide interventions have been found to be successful in reducing bullying and impact the overall peer dynamics that support it (Hayden-Wade et al. 2005). Social workers can assist school administrators in developing interventions aimed at reducing stigmatization school wide by challenging the degree to which stigmatization and victimization are sanctioned by the peer group (Gray et al. 2009).
As mentioned earlier, parents unwittingly convey stereotypes to their children either through focusing on the importance of being thin (Latner et al. 2007) or through conveying weight stereotypes through story-telling activities (Adams et al. 1999). Interventions targeting parents by increasing their awareness of the impact of the messages they intentionally and unintentionally send to their children may prove to be an effective strategy for countering weight bias, and subsequently, peer victimization (Gray et al. 2009).
Macro Level Implications
Our society idealizes thinness and sends the message that it is inappropriate to be obese (Gray et al. 2009). Targeting society as a whole is perhaps the most daunting task in reducing obesity stigmatization (Gray et al. 2009); however, macro level interventions are a critical component in reducing weight based stigmatization. As mentioned earlier, the media, particularly magazines and television perpetuate the thin is ideal weight bias (Latner et al. 2007). Therefore popular media is the logical avenue for a campaign aimed at reducing weight based stigmatization. Media-literacy approaches have been effective in reducing other undesirable behaviors among children (Irving and Neumark-Sztainer 2002) such as alcohol use and have the potential for large-scale impact on reducing weight bias (Gray et al. 2009). Levine and Smolak (2001) outline the “five A’s” of media literacy in terms of how they can be applied to approaching prevention of eating disorders; Irving and Nuemark-Sztainer (2002) propose that this approach may also be used in preventing obesity. The A’s are (1) awareness; (2) analysis; (3) activism, (4) advocacy; (5) access (Levine and Smolak 2001). These ‘A’s’ can be taken one step further in terms of reducing stigmatization of obesity. Raising the awareness of the impact of parents in forming negative stereotypes is important in the reduction of stigma. Because parents are often unaware of the biases they create in their storytelling, the media is an important vehicle in conveying this message. Analysis of not only “thin” images portrayed in the media (Levine and Smolak 2001) but also of the negative stereotypes portrayed is also important. In terms of activism and advocacy, social workers need to be vocal in protesting the negative images portrayed by overweight character on television (single, unemployed, unpopular) and advocating for a positive portrayal of overweight individuals. Social workers need to join the fight against obesity and the stigmatization of overweight people by gaining access to media venues and sending messages to the general public about the consequences of overweight stigmatization.
Future Research Implications
The majority of research surrounding the consequences of the stigmatization of obese children has been cross-sectional (Gray et al. 2009). While valuable, cross sectional research does not draw any conclusions about causality. While stigmatization and victimization have been associated with psychological, social and academic consequences, causality cannot be assessed. It is possible that children who are obese are more likely to be victimized because they have a low self esteem and are vulnerable (Gray et al. 2009), making them easy targets.
While limited research has indicated that parents may play a role in the formation of childhood biases, the findings have been consistent and discouraging (Puhl and Latner 2007). More research is needed to examine the nature and the impact of the stigma communicated by parents and whether this weight stigma applies to parents of both obese and nonobese youth. It is also important to identify whether weight stigmatization is a potential mediator between obesity and academic achievement.
The current generation of children and adolescents spend an inordinate amount of time using media based modes of communication (Instant messenger, texting, tweeting, peer based websites), providing additional avenues for victimization of obese youth. There are no data addressing the role of cyberbullying of obese youth (Gray et al. 2009). Given the extent of face to face bullying, it would stand to reason that obese youth are also victimized through websites and mobile telephones. Future social work research should focus on the impact of E-Bullying of obese youth.
While it is axiomatic that developing interventions aimed at reducing obesity prejudice in an important target of social work intervention, it is of equal if not greater importance to develop interventions focusing on the adoption of health eating and physical activity habits. Social workers are equipped to develop or collaborate in interventions at the primary, secondary and tertiary levels. The American Academy of Pediatrics, Council on School Health provides recommendations for schools to form school wellness counsels comprising doctors, nurses, dieticians, parents, and other community members (Spear et al. 2007). Social workers are not specifically mentioned by the committee, however, they provide an avenue for advocacy on the micro, mezzo, and macro levels. It is critical for social workers to become more vocal about their potential role in pediatric obesity prevention to enhance their potential for collaboration with school administrators and teachers (Lawrence et al. 2010). This could be taken one step with incorporation of de-stigmatization intervention in concert with healthy choice adoption strategies can increase the chances of long term positive outcome.
Mental health professionals’ biases against obese individuals are largely under researched. A study by Young and Powell (1985) found that mental health professionals are more likely to assign negative mental health symptomatology to obese individuals than to “normal” weight or overweight individual. The researchers also found that males were less “harsh” than females in terms of assessment. Similarly older mental health workers were less likely than their younger counterparts to assign negative symptoms to the obese clients (Young and Powell 1985). Similar results were found by Davis-Coelho et al. (2000). The researchers studied individuals in various psychology practices and found that younger psychologists were likely to predict a lower degree of effort from the client and a poorer prognosis. It was also reported that female psychologists were more likely to predict a poor prognosis. There have been no studies conducted assessing the attitudes or diagnostic biases of social workers in terms of obesity.
No social group is immune to obesity stigma (Carr and Friedman 2005). Some studies suggest that obesity discrimination is comparable across race, gender and age demographics (Carr and Friedman 2005), others have found variations among these groups (Latner et al. 2007). One study found that African American women indicated more favorable opinions toward obesity than African American men, and European American men and women. Crandall and Martinez (1996) found that students at an American university stigmatized overweight people significantly more than students at a Mexican university. Negative attitudes towards obesity in a multicultural society, such as that of the United States, may be dependent on cultural identity and acculturation (Lewis and Van Puymbroeck 2008). As social workers develop micro, mezzo and macro interventions designed to address obesity and its stigmatization, it will be necessary to develop specific interventions with a culturally sensitive focus tailored to diverse communities (Lawrence et al. 2010). Efforts are currently being undertaken by the World Health Organization to develop strategies within the European Union that may begin to address cultural issues related to country-specific issues on a macro level (Stroup et al. 2009). Social workers should draw upon the professional strengths of cultural sensitivity and the strengths perspective within these community-based roles, both locally and globally.
Obese youth report being victimized at a rate that is up to twice as high as rates reported among nonobese adolescents (Hayden-Wade et al. 2005). It is clear that interventions on micro, mezzo and macro levels are needed to address this growing problem of the victimization of youth who are overweight or obese. However, because of the myriad of health issues associated with obesity, these interventions must include a focus on making health food and exercise choices. Social workers are in a unique position to develop and implement programs with a two-pronged approach that addresses both healthy eating and victim protection (Eliadas 2006). Given social work’s traditional commitment to the person-in-environment perspective practitioners understand that problems, such as obesity and stigmatization, are systemic, and as such require interventions that incorporate many systems within a child’s environment. Social workers heeding the call to action can work to help stakeholders redefine the dual problems of obesity and stigma from an ecological perspective in which the problem is neither independently a personal or public problem (Lawrence et al. 2010). Addressing the victimization that often results from stigma will enhance the development of interventions that reduce both childhood obesity, and its resultant stigma while at the same time increasing self-confidence and self-efficacy of overwieght children.