The Stigma of Obesity: A Review and Update

Obese individuals are highly stigmatized and face multiple forms of prejudice and discrimination because of their weight (1,2). The prevalence of weight discrimination in the United States has increased by 66% over the past decade (3), and is comparable to rates of racial discrimination, especially among women (4). Weight bias translates into inequities in employment settings, health-care facilities, and educational institutions, often due to widespread negative stereotypes that overweight and obese persons are lazy, unmotivated, lacking in selfdiscipline, less competent, noncompliant, and sloppy (2,5–7). These stereotypes are prevalent and are rarely challenged in Western society, leaving overweight and obese persons vulnerable to social injustice, unfair treatment, and impaired quality of life as a result of substantial disadvantages and stigma. In 2001, Puhl and Brownell published the first comprehensive review of several decades of research documenting bias and stigma toward overweight and obese persons (2). This review summarized weight stigma in domains of employment, health care, and education, demonstrating the vulnerability of obese persons to many forms of unfair treatment. Despite evidence of weight bias in important areas of living, the authors noted many gaps in research regarding the nature and extent of weight stigma in various settings, the lack of science on emotional and physical health consequences of weight bias, and the paucity of interventions to reduce negative stigma. In recent years, attention to weight bias has increased, with a growing recognition of the pervasiveness of weight bias and stigma, and its potential harmful consequences for obese persons. The aim of this article is to provide an update of scientific evidence on weight bias toward overweight and obese adults through a systematic review of published literature since the 2001 article by Puhl and Brownell. This review expands upon previous findings of weight bias in major domains of living, documents new areas where weight bias has been studied, and highlights ongoing research questions that need to be addressed to advance this field of study. A systematic literature search of studies published between January 2000 and May 2008 was undertaken on computerized psychological, medical, social science, sport, and education databases including PsycINFO, PubMed, SCOPUS, ERIC, and SPORTDiscus. The following keyword combinations were used: weight, obese, obesity, overweight, BMI, fat, fatness, size, heavy, large, appearance, big, heavyweight, bias, biased, discrimination, discriminatory, discriminate, stigma, stigmatized, stigmatization, prejudice, prejudicial, stereotype(s), stereotypical, stereotyping, victimization, victimize(d), blame(d), blaming, shame(d), shaming, teasing, tease(d), unfair, bully, bullying, harassment, assumptions, attributions, education, health, health care, sales, employment, wages, promotion, adoption, jury, customer service, housing, media, television. Reference lists of retrieved articles and books were also reviewed, and manual searches were conducted in the databases and journals for authors who had published in this field. Most studies retrieved for this review were published in the United States. Any articles published internationally are noted with their country of origin. Research on weight stigma in adolescents and children was excluded from this review, as this literature was recently reviewed elsewhere (8). Unpublished manuscripts and dissertations were also excluded. In addition, issues pertaining to measurement of weight stigmatization, and demographic variables affecting vulnerability to weight bias such as gender, age, race, and body weight are not addressed in this review. This article instead primarily reviews the evidence of specific areas where weight bias occurs toward adults and its consequences for those affected. This article is organized similarly to the first review published by Puhl and Brownell (2), with sections on weight bias in settings of employment, health care, and education. New sections have been added including weight bias in interpersonal relationships and the media, as well as psychological and physical health consequences of weight bias, and the status of stigma-reduction research. As with the 2001 article, this review also provides an update on legal initiatives to combat weight discrimination, and outlines specific questions for future research.