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Running Head: RESEARCH PAPER The Consequences of the Stigmatization of Fat Children and Adolescents Alison Maffucci Westmont College Author’s Note Alison Maffucci, Department of Psychology, Westmont College I want to thank my roommates for dealing with me and for my dietitian who got me interested in the stigmatization of weight. Correspondence regarding this essay should be addressed to Alison Maffucci, Westmont College, 955 La Paz Road MS #2000, Santa Barbara, CA 93108 (APA 2012). Email: [email protected] 2 RESEARCH PAPER Abstract The prevalence of overweight and obese children is increasing in the United States. While there are legitimate health concerns associated with obesity, body size stigmatization has clear negative consequences for overweight children. This high rate of obesity might suggest that weight tolerance would actually increase, but evidence in recent years indicates that weight bias remains widespread and is worsening. As obesity becomes a national public health priority, it is important for our society to understand the nature of weight stigma and its effect on youth. A stigmatized child possesses an attribute or characteristic that is linked to a devalued social identity and is ascribed stereotypes or other deviant labels that increase vulnerability to status loss, unfair treatment, prejudice, and discrimination. Children are described at risk for overweight if their body mass index is within the range to the 85-94th percentile and overweight if their BM! Isa t the 95th percentile or higher. 3 RESEARCH PAPER Introduction As childhood obesity and overweight rates continue to rise, an increasing number of young people are vulnerable to the social consequences of obesity. There is reason to be concerned about the vulnerability of so many children to the negative social, emotional, and physical consequences of obesity. In the culture of the United States, thinness symbolizes attractiveness, power, and self-control, while unfortunately people who are not thin are assumed to be indulgent, lazy, and lacking in self-discipline. Even children internalize this cultural message and place great importance on being thin, and many even desire thinner bodies even if they fall within normal weight ranges. Overweight and obese children and adolescents are the targets of societal stigmatization in multiple aspects of their lives. Research suggests that overweight and obese youths are victims of bias and stereotyping by peers, educators, and even their own parents and family members. Fat children are increasingly excluded, 4 RESEARCH PAPER treated differently, and viewed as flawed. Stigmatization does not only affect psychological well being, but also damages social relationships, academic success, and can trigger destructive behaviors. This piece defines weight stigma as negative weight related attitudes and beliefs that are manifested by stereotypes, bias, rejection, and prejudice toward children and adolescents because they are overweight or obese. Anti-Fat Attitudes in Youth Negative attitudes towards obese youth develop in children, probably because this bias remains socially acceptable in our culture. Children are not afraid of becoming fat due to the health risks associated with obesity, but because they have an early awareness that having a fat body is socially unacceptable in our culture. Research shows that stereotypes towards obese children begin as young as three years old, where preschoolers report their overweight peers as mean, stupid, ugly, unhappy, lazy, and undesirable friends. Attitudes worsen as children enter elementary and middle school, with obese peers being described as ugly, selfish, lazy, stupid, and dishonest. There have been numerous studies that have documented children’s negative attitudes towards obese and overweight individuals. A standard technique for assessing anti-fat attitudes is to note reactions to figures of various body sizes, from very thin to very fat. Research shows that children hold the most negative attitudes toward the overweight figures. In a 1961 study, Richardson, concluded that ten to eleven year olds rate overweight children as the least likable. In a 2003 replication 5 RESEARCH PAPER of this study, weight stigma has even worsened among children, which means that our anti-fat attitudes are only getting worse. Children like overweight peers less and wish to interact with them less than average weight peers. Given the stigmatization of overweight and obese youth, these children will suffer through more negative peer interactions and fewer opportunities for developing social skills and supportive social relationships. The acceptability of fat prejudice and much of the hostility directed toward fat people is supported by the belief that fat people can become thin if they really wanted. Children’s perceptions of the controllability of weight might be related to body size stigmatization and their friendship selections based on body size. It is possible that children characterize overweight individuals more negatively than those with other physical attributes, because they see this condition as the fault of the overweight person. Tiggemann and Anesbury found that 8-12 year old children on average believed that obesity was controllable, and that the more strongly the children held this belief, the more strongly they held negative stereotypes about overweight individuals. Weight Bias and Peer Teasing Teasing is a widely documented source of psychological distress and is considered the most psychologically harmful type of peer victimization. Being teased because of one’s weight or appearance is related to negative body image and weight concerns in children and adolescents. One-quarter of girls and 12 percent of boys who were teased reported attempting suicide compared to those who were not RESEARCH PAPER 6 teased. Weight bias can be expressed verbally, through physical aggression, or through social exclusion. Nearly all children are teased, but some may have a higher likelihood of experiencing chronic teasing. In elementary school, the likelihood of being bullied is 63 percent higher for an obese child compared to a healthy weight child. Approximately one-third of overweight girls and one-fourth of overweight boys report being teased by peers at school, while 60 percent of girls and boys who are obese report victimization. The National Education Association conducted a study that aimed to figure out the different types of weight-based victimization that students experience in school. In a survey of 1555 overweight and obese adolescents, 92% report being made fun of, 91% report being called names, 85% report being teased during physical activity, 71% report being teased in the cafeteria, and 76% felt ignored and avoided. In middle school, weight related teasing elicits the most negative emotional reactions compared to teasing for other reasons. Michael Loewy, a psychology professor at the University of North Dakota says in his essay Working with Fat Children in Schools: “It is amazing that so many fat children survive adolescence, given the hatred and meanness directed at them.” Compared to average weight children, obese children report to be teased at least three times more often. Chronic teasing may lead to social isolation, since there exists correlations of degree of weight related teasing with weight concerns, loneliness, and liking of sedentary and isolative activities. Data from 90,118 adolescents in the National Longitudinal Study of Adolescent Health found that 7 RESEARCH PAPER overweight adolescents were more likely to be socially isolated and were less likely to be chosen by their peers as friends. Weight Bias in Education Peers are not the only sources of weight stigmatization in the educational setting. Anti-fat beliefs are concerning because even teachers exhibit biased attitudes. Teacher biases can influence student academic outcomes and performance, and student self-perceptions. Research shows that educators report having lower expectations for overweight students and that they believe overweight students have worse social, reasoning, physical, and cooperation abilities than non overweight students. This means that weight bias within educational institutions may prevent obese individuals from achieving the same educational goals as their normal weight peers. For fat students, the school experience is one of ongoing prejudice and socially acceptable discrimination. Obese students have been found to have lower college acceptance rates and are encouraged less from their high school counselors to even apply to college. Perceived or actual bias and discrimination from teachers has negative effects on the students’ well being. Teacher bias may also make overweight students less likely to participate in activities that draw additional attention to their weight, such as physical education class. Getting teased about being overweight often occurs during times when children are engaging in physical activities. Bauer and colleagues found that middle school students reported receiving negative comments from teachers about their athletic abilities that in turn led them to avoid participating in PE classes. 8 RESEARCH PAPER Overweight youth often report that weight based teasing is ignored by PE teachers. If teachers themselves have high levels of anti-fat bias, then they may not stop weight based teasing when it occurs in their classes. Due to weight based teasing, students report that their grades are harmed and that they avoid school. In a random sample of 1071 public school students, being overweight predicted poorer school performance. In school setting, students who are overweight or obese can face harassment and ridicule from peers, as well as negative attitudes from teachers and other educators. At the college level, some research shows that qualified overweight students, particularly females, are les likely to be accepted to college than their normal weight peers. BMI Screening in Schools In 2003, Arkansas was the first state to require schools to chart its students’ Body Mass Index. Three years later, the state’s percentage of overweight school children remained the same. Miriam Berg, president of the National Council on Size and Weight Discrimination says, “Weighing children regularly does not help them become thin.” Berg is opposed to the promotion of weight loss as public policy because: 1) it targets fat kids and promotes discrimination against them, 2) it teaches kids that fatness should be avoided at all costs, resulting in dangerous diet practices and eating disorders, and 3) it ignores the nutritional, exercise, and health needs of kids who are average weight or thinner on average. The medical community is doing a disservice to thin kids by focusing solely on kids who are overweight. RESEARCH PAPER In a study assessing if BMI screening in schools is helpful or hurtful, the Center of Disease Control concluded that there was insufficient evidence to recommend that schools conduct BMI screening and report these results to the parents. The US Department of Agriculture/ Agriculture Research center investigated the adequacy of using BMI to assess the weight of children in a multiethnic population. Their conclusion was that 17% of children with normal percentages of body fat were incorrectly classified as at risk of overweight or overweight. There is concern that schools are falsely mislabeling a large number of children based on the BMI screening. It is critical to understand that obesity prevention and health promotion programs can actually harm one aspect of health while attempting to improve another. According to a policy statement on Prevention of Pediatric Overweight and Obesity (2004) by the American Academy of Pediatrics, BMI has its limits as an accurate measurement of obesity. Children grow unevenly, often gaining weight before growing in height. Some children are also more muscular due to physical activity and genetic factors, so despite a lean body mass, their weight and BMI are higher. John S. Martinez School in New Haven, Connecticut, was one of the first elementary public schools in its district to rid its campus of all junk food. The schools health clinic monitors each child’s health and weight loss. The eighth graders say that the schools efforts to keep them thin have increased their fear rather than reduced their weight. The messages being received by our youth is lose weight to get healthy, which contributes to anxiety and depression. Health 9 10 RESEARCH PAPER education messages that focus on the negative impact of dietary fat, overweight, and weight control are likely to make young people feel worse about their bodies and themselves in general. Child obesity prevention programs and untested health education messages have the potential to further stigmatize fat children and perpetuate the current prejudicial beliefs. Even Parents Tease Parents who hold their own anti-fat attitudes want to protect their children from the discrimination that fat people experience, however, parental encouragement of their children to be within socially acceptable weight limits can be detrimental to the child. Research shows that parental modeling of excessive weight concern and disordered eating is related to higher weight concern in their children. Parental teasing and concern for their child’s body shape has been found to be detrimental to a child’s psychological wellbeing. Many parents worry about their children’s weight in elementary school. Parents may ridicule the child’s eating habits, force their child to diet, insult them, or shame them into losing weight. Research shows that 47 percent of overweight girls and 34 percent of overweight boys report weight victimization from their own family. There have been a number of studies the address the relationship between reported parental attempts to control children’s food intake and the amount of food children actually eat. Mothers who are concerned about their child’s weight are more likely to restrict their child’s eating. Fisher and Birch found that when mothers 11 RESEARCH PAPER tried to control their daughters’ food intake, when the daughters were given free access to the restricted foods, the daughter increased her food intake. In the only study examining the reaction of parents to a BMI report card, a significant number of parents responded to the news that their children were overweight by putting the children on calorie-restricting diets. Limiting calorie intake in children before puberty is problematic because it stunts growth in height, and also leads to behavioral problems, such as sneaking food, hiding food, and overeating. It is in the home where food and fat will be experienced for the growing and developing child. Children’s perceptions of parental pressure to maintain a low body weight, increases the likelihood of weight dissatisfaction and eating disorders. In addition parental concern about their child’s weight and body image is significantly correlated with children’s tendency to hold stereotypical views about fat people, which continues the prevalence of the stigma and fear of fat. Weight Bias and Emotional Well-Being We live in a society where messages depict fatness as unhealthy and also unsightly and immoral. Overweight people feel undesirable, unattractive, and devalued by society’s standards. Weight bias has a range of negative consequences for children and adolescents who are overweight and obese. Emotional consequences of bias include increased vulnerability to depression and anxiety, lower self-esteem, and poor body image. In addition, research shows that obese youth who are victimized by their peers are more likely to engage in suicidal thoughts and behaviors than overweight children who are not victimized. There is RESEARCH PAPER 12 reason to be concerned about the vulnerability of so many children to the negative social and emotional consequences of the overweight and obese stigma. Experiences of weight bias and stigma have harmful psychological and social consequences, such as isolation or withdrawal. Studies have demonstrated that when children internalize the bias, they are more likely to binge eat in response to stigma. Obese children of both sexes report having low self esteem, and exhibit high rates of extreme dieting, disordered eating, and skipping breakfast, as well as greater levels of emotional distress and lower expectations of their educational futures. The sense that one has been treated unfairly in public places can have negative consequences for sentiment and emotional health. Obese groups score lower in physical and general self-esteem scales compared to control groups, and there is a high prevalence of psychiatric disorders in obese groups. In the study done by_______ 70 percent of the participants met the criteria for at least one of the DSM-IV diagnosis. The rate of anxiety disorders seems to be higher in obese children and adolescents in in-patient settings for binge eating, than in other chronic diseases. Adolescents frequently struggle with their self-esteem and want to be accepted by their peers, and are especially vulnerable if they happen to be heavier than most in their class. Children and adolescents are battered by ruthless pressure to be thin at a time when fitting in is of most concern. Heavier children report more psychological and weight related distress. Depression is associated with weight related teasing and also with children’s report of body size dissatisfaction. In a study 13 RESEARCH PAPER researching_________, obesity was significantly related to depression among 15 and 17 year olds and also related to experiences of shame. The prejudices against fat people are perceived and internalized by children. Turning around fat discrimination is an important part of helping our overweight children achieve and maintain a healthy weight, because a society intolerance of fat bodies makes overweight or at risk overweight children even fatter. Overweight children who are teased are more likely to engage in unhealthy weight control and binge eating behaviors. There is also evidence to suggest that obese children are less likely to engage in physical activity because of weight stigma. In a sample of over 2,000 overweight and obese women, Phil concluded that weight related stress and dissatisfaction explains a large portion of obesity’s effect on health. 79 percent of the sampled women indicated that they coped with the weight stigma by eating more food. Discrimination against overweight children by other children and adults often pushed children to isolate and eat more and exercise less. Discrimination for their Own Good Having too much excess weight is linked to ill health and mortality. Long lists of diseases are associated with obesity and overweight: heart disease, cancer, hypertension, lipid-dysregulation, type 2 diabetes, and many others, but overlooked entirely is the impact obesity may have on health through its social consequences. Societal weight bias and discrimination may be linked to important health outcomes that the medical and scientific fields have failed to consider. RESEARCH PAPER 14 Childhood obesity has been identified as a major threat to children’s health in the USA. The number of Americans classified as obese has increased and is described by the media and medical community as an obesity crisis. A third of Americans are obese and another third are overweight. In California, statistics show that one in three adolescents age 9-11 are at risk of or are already overweight. Obesity is associated with diabetes, heart disease, cancer, high blood pressure, and sleep apnea. 60 percent of overweight children have developed at least one cardiovascular risk factor (i.e. high blood pressure, lipid levels, or impaired glucose tolerance) and 20 percent of over-weight children have two or more of these. Despite the alarm, most intervention and treatment is viewed at the individual level. Excess weight has a pervasive effect on a host of bodily systems: metabolism, endocrinology, respiration, musculoskeletal integrity. It is not uncommon to hear that stigma is beneficial because it serves as an incentive for people to avoid gaining weight and helps motivate overweight people to diet. However, their remains no evidence that weight teasing directed at children is a positive motivator to lose weight. Our society has declared a war on fat, “with no study to demonstrate even the possibility of long-term successful weight loss, but backed by a 50 billion dollar per year weight loss industry, this war is both under researched and overfunded.” Fat children are the most innocent of society’s victims. Politicians are reacting with legislation: BMI report cards sent home to parents, removal of soft drinks and junk food from schools, banning trans fats in restaurants, and requiring fast-food chains to display the caloric content of their food. Americans are actually enjoying longer lives and better health than ever RESEARCH PAPER 15 before. The claim that four out of five of us have serious health risks because of a number on a scale further stigmatizes fat people and contributes to a culture that fears fat. Several researchers have argued that weight should be less of a public health priority. A 2005 study by scientists at the Centers of Disease Control and Prevention (CDC) suggested that it is only after BMI reaches 35 that there is a meaningful increase in mortality and that people in the overweight category actually have the lowest rate of mortality. Dr. David Satcher warns that obesity may soon pass tobacco as the chief cause of preventable deaths in the United States. Obesity is claimed to be the world’s number one health problem, with the potential to reduce life expectancy by ten years or more (Fox). About 60 percent of adults in this country are overweight or obese, as are nearly 13 percent of children. (New York Times 2001a: 2) In April 2004, researchers from the Centers for Disease Control and Prevention released a report in the prestigious Journal of the American medical Association estimating that obesity was killing 400,000 Americans a year. This resulted in public health officials using these numbers in the news and in congress declaring obesity as a major threat to the American public. However, the researchers from the Centers for Disease Control did not record to see if the weight of each person was a factor in his or her death. Real morbidity/mortality correlations with weight have often been contradictory with its findings. There have been cases were being fat protects against disease and heavier people live longer. It is assumed that the increase in child obesity has occurred because of an increase in caloric intake, however, data has not confirmed this assertion. The claim RESEARCH PAPER 16 that obese children and adolescents consume more calories than their normalweight peers conflicts with several studies, which indicate there being no difference in total energy intake between the two groups. In the Bogalusa Heart Study that followed the health and nutrition of children in Bogalusa, Louisiana since 1973 noted that total caloric intake for ten-year-old children remained virtually unchanged from 1973-1988. The U.S. Department of Agriculture’s National Food Consumption Surveys and Continuing Survey of Food Intake by Individuals indicates a downward trend in the mean energy intake for the general population from 1965-1991, but an increase in the caloric intake for the years 1994 and 1995. This data reveals that childhood obesity increased for many years without an increase in caloric intake. The hypothesis that decreased caloric expenditure in the population is a significant contributor to the current obesity epidemic remains unproven. Richard Klein, a well-known critic of the war on fat, pointed to the growing awareness of our culture on dieting and rigid exercise is the root cause of the fat explosion of our country. Turning around fat discrimination is an important part of helping our overweight children achieve a healthy weight. A society obsessed with thinness and that is intolerant of fat bodies, makes overweight children even fatter. Health is not a number and is problematic when linked with weight. The assumption that fat people are unhealthy is so ingrained in our society. Healthy dayto-day practices should be emphasized regardless to whether a person’s weight changes. Increasingly, even medical researchers are acknowledging that excess body weight is harmful for health not solely on a physiological basis but in part because of 17 RESEARCH PAPER the stress associated with enduring an unfavorable social trait. Psychological distress and discrimination affect our physical health. The social stigma of obesity worsens the cycle of poor eating and poor exercise routines. If perceived discrimination adds extra health challenges to the ones that already obese and overweight children face, it is possible that the internalization of the weight stigma explains the exacerbation of the effects. Encouraging children of all sizes toward emotional health and a sense of self-worth encourages physical health. It is important to practice healthy habits no matter how much you weigh. Conclusion Successful efforts to prevent and reduce childhood obesity and overweight should be programs to reduce weight stigma. Discrimination against overweight children by other children and adults often pushes them to eat more and exercise less. And numerous studies document how fat kids, victims of discrimination and bullying, often respond by withdrawing from peers or becoming bullies themselves. "I believe if a child is eating a nutritionally balanced diet and is active, if he or she has a higher BMI [body mass index], it doesn't matter," says Schwartz. Schwartz routinely hears people say, "If only fat people worked harder, they would lose weight." But she and others challenge RESEARCH PAPER 18 the hysteria surrounding the global "obesity epidemic," which defines 17 percent of children age 2 to 19 as overweight. Paul Campos, author of The Obesity Myth, argues that Americans are, in general, only 15 pounds heavier than they were 20 years ago. It is public health standards, not our bodies, that have changed, becoming more rigid in defining the majority of Americans as "overweight." 19 RESEARCH PAPER References Franklin, J., Latner, G., Steinbeck, K. S., Caterson, I. D., & Hill, A. J. (2006). Obesity and risk of low self-esteem: A statewide survery of australian children. Pediatrics, 118(6), 2481-2487. Ikeda, J. P., Crawford, P. B., & Woodward-Lopes, G. (2006). Bmi screening in schools: helpful or harmful. Health Education and Research, 21(6), 761-769. Puhl, R. M., & Heuer, C. A. (2009). Obesity stigma: Important considerations for public health. American Journal of Public Health, 100(6), 1019-1028. Puhl, R. M., & Latner, J. D. (2007). Stigma, obesity, and the health of the nation's children. Psychological Bulletin , 133(4), 557-580.