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2015 Stigmatisation and obesity: literature update Stigmatisation and obesity: Literature update February 2015 Published February 2015 by the UK Health Forum for the Obesity Learning Centre UK Health Forum, Fleetbank House, 2-6 Salisbury Square, London, EC4Y 8JX The Obesity Learning Centre (OLC) is the nationwide centre for quality assured information for everyone working in obesity. The OLC sets out to strengthen and support local capacity and capabilities to treat overweight in children and adults. The OLC is maintained by the Research Information Services team at the UK Health Forum and works closely with Public Health England. The Obesity Learning Centre is maintained and provided by the UK Health Forum. www.obesitylearningcentre.org.uk The UK Health Forum is a charitable alliance of professional and public interest organisations working to reduce the risk of avoidable non-communicable diseases (NCDs) by developing evidence-based public health policy and supporting its implementation through advocacy and information provision. www.ukhealthforum.org.uk Obesity Learning Centre Literature Update: Stigmatisation and obesity. February 2015 1 Inside this literature update Contents Stigmatisation and obesity: Literature update .................................................................................... 1 February 2015 ............................................................................................................................................... 1 Inside this literature update ............................................................................................................................ 2 About this literature update ....................................................................................................................... 3 ........................................................................................................................................................................ 4 Attitudes towards and perceptions of obesity affecting children and young people ..................... 4 Obesity and stigmatisation in health and care settings ......................................................................... 9 Public perceptions of and attitudes towards obesity........................................................................... 13 Stigmatization of and discrimination against obese individuals in the workplace .......................... 17 Portrayals of obesity in the media ........................................................................................................... 18 Effect of stigmatization.............................................................................................................................. 19 Measuring stigmatization .......................................................................................................................... 22 Self-perception and self-stigmatization in obese individuals............................................................... 23 Obesity stigmatization and public health planning.............................................................................. 27 Further reading ........................................................................................................................................... 28 Appendix: Search strategy ....................................................................................................................... 38 PubMed & Cochrane Library MeSH search strategy ........................................................................ 38 Google Scholar search strategy .......................................................................................................... 38 Search record ......................................................................................................................................... 38 Obesity Learning Centre Literature Update: Stigmatisation and obesity. February 2015 2 About this literature update This literature update has been designed and carried out by qualified information professionals at the UK Health Forum in order to provide an update on published literature on the topic of stigmatization issues relating to obesity. This topic has been selected for the final update in this series in order to highlight the importance of understanding the impact of stigma on people who are obese, not just in terms of their own mental health and well-being, but also their access to services and experience of discrimination, and the influence of public perceptions on policy making. The search carried out to prepare this update was not a systematic literature search, and was carried out purely for the purposes of delivering a brief update on the named topic. The aim of this update is to highlight open access research on the named topic. The body of the document contains links to open access research, while the ‘Further reading’ section contains details of content accessible by subscription only. If you require a comprehensive update on the named topic you are advised to carry out a systematic search using a full range of appropriate databases. Readers should note that absence of evidence does not indicate absence of effect. The area covered by this update is an area where the amount and level of available evidence is still developing. This update focuses on peer reviewed and commercially published research, with some unpublished or ‘grey’ non-commercially produced literature such as government reports, policy documents, or publications produced by organisations such as charities and NGOs. If you require a comprehensive update on grey literature for the named topic you are advised to include grey literature sources in your search. The UK Health Forum produces a weekly news and grey literature update service and eLibrary called Prevention Information and Evidence. This eLibrary contains obesity and nutrition grey literature and is available from the Obesity Learning Centre website: http://www.obesitylearningcentre.org.uk/resources/prevention-information-evidence/ To assist the reader the results of the search have been presented in themes as follows: Attitudes towards and perceptions of obesity effecting children and young people Obesity and stigmatisation in health and care settings Public perceptions of and attitudes towards obesity Stigmatization of and discrimination against the obese in the workplace Portrayals of obesity in the media Effect of stigmatization Measuring stigmatization Self-perception and self-stigmatization in obese individuals Obesity stigmatization and public health planning Obesity Learning Centre Literature Update: Stigmatisation and obesity. February 2015 3 The articles included in this update are open access. Follow links provided in PubMed to access full text. Attitudes towards and perceptions of obesity affecting children and young people ANESBURY, T. & TIGGEMANN, M. 2000. An attempt to reduce negative stereotyping of obesity in children by changing controllability beliefs. Health Educ Res, 15, 145-52. Access full text: http://www.ncbi.nlm.nih.gov/pubmed/10751373 Aim: The purpose of the present study was to investigate whether changing children's beliefs about the controllability of obesity would reduce their negative attitudes toward fat people. The participants were 74 children from Grades 4-6, 42 in the experimental group and 32 in the control group. The experimental group were presented with a brief intervention which focussed on the uncontrollability of weight. Conclusion: The study found that the intervention was successful in reducing the amount of controllability that children assigned to obesity, but was not successful in reducing negative stereotyping of the obese among the experimental group compared to the control group. These results indicate that while children's beliefs about the controllability of obesity can be changed, reducing their negative stereotyping is more difficult. BELL, S. K. & MORGAN, S. B. 2000. Children's attitudes and behavioral intentions toward a peer presented as obese: does a medical explanation for the obesity make a difference? J Pediatr Psychol, 25, 137-45. Access full text: http://jpepsy.oxfordjournals.org/content/25/3/137.full.pdf Aim: To examine the effect of information on children's attitudes and behavioral intentions toward a peer presented as obese. Conclusion: Ratings were generally more favorable for the average-weight than for the obese condition. However, provision of medical information had a positive effect on attitudes toward the obese peer only for younger children and a negative effect on willingness of older children to share academic activities with the peer. Boys and girls showed more positive behavioral intentions toward the same-sex target child regardless of obesity condition. Information explaining obesity has a minimal positive effect on children's attitudes and behavioral intentions toward a peer presented as obese. BURMEISTER, J. M., KIEFNER, A. E., CARELS, R. A. & MUSHER-EIZENMAN, D. R. 2013. Weight bias in graduate school admissions. Obesity (Silver Spring), 21, 918-20. Access full text: http://www.ncbi.nlm.nih.gov/pubmed/23784894 Aim: Whether weight bias occurs in the graduate school admissions process is explored here. Specifically, we examined whether body mass index (BMI) was related to letter of recommendation quality and the number of admissions offers applicants received after attending in-person interviews. Conclusion: Higher BMI significantly predicted fewer post-interview offers of admission into Obesity Learning Centre Literature Update: Stigmatisation and obesity. February 2015 4 psychology graduate programs. Results also suggest this relationship is stronger for female applicants. BMI was not related to overall quality or the number of stereotypically weightrelated adjectives in letters of recommendation. Surprisingly, higher BMI was related to more positive adjectives in letters. The first evidence that individuals interviewing applicants to graduate programs may systematically favor thinner applicants is provided here. A conscious or unconscious bias against applicants with extra body weight is a plausible explanation. Stereotype threat and social identity threat are also discussed as explanations for the relationship between BMI and interview success. DAVISON, K. K. & BIRCH, L. L. 2004. Predictors of fat stereotypes among 9-year-old girls and their parents. Obes Res, 12, 86-94. Access full text: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2530916/ Aim: To assess familial links in fat stereotypes and predictors of stereotypes among girls and their parents. Conclusion: Girls and parents exhibited fat stereotypes. Fathers who were more educated and had a higher family income were more likely to endorse fat stereotypes, as were mothers and fathers with a high investment in their physical appearance. Although no associations were found between girls' and parents' fat stereotypes, girls were more likely to endorse fat stereotypes when interactions with parents and peers focused on body shape and weight loss. Girls were also more likely to endorse fat stereotypes when they reported higher levels of maladaptive eating attitudes. No associations were found between weight status and fat stereotypes. EDMUNDS, L. D. 2005. Parents' perceptions of health professionals' responses when seeking help for their overweight children. Fam Pract, 22, 287-92. Access full text: http://www.ncbi.nlm.nih.gov/pubmed/15772121 Aim: The aim was to explore parents' perceptions of help-seeking experiences with health professionals. Conclusion: Parents went through a complex process of monitoring and self-help approaches before seeking professional help. The responses they received from GPs included: being sympathetic, offering tests and further referrals, general advice which parents were already following, mothers were blamed, or dismissed as "making a fuss", and many showed a lack of interest. Health visitors offered practical advice and paediatric dietitians were very supportive. Experiences with community dietitians were less constructive. GREENLEAF, C., MARTIN, S. B. & RHEA, D. 2008. Fighting fat: how do fat stereotypes influence beliefs about physical education? Obesity (Silver Spring), 16 Suppl 2, S53-9. Access full text: http://www.ncbi.nlm.nih.gov/pubmed/18978764 Aim: The purpose of this study was to examine college students' beliefs about youth obesity, the roles of schools and physical education in addressing obesity, and the training they receive to work with overweight youth. Conclusion: The importance of youth being normal weight was rated most highly among participants in physical education-related majors and among those who endorsed fat stereotypes. Participants who endorsed fat stereotypes, compared to those who did not, were more likely to believe that all school professionals should be involved in treating childhood obesity. Participants who endorsed fat stereotypes, compared to those who did not, more Obesity Learning Centre Literature Update: Stigmatisation and obesity. February 2015 5 strongly agreed that physical educators should be role models by maintaining normal weight and educating parents on childhood obesity, and PE classes should focus on lifelong fitness. No group differences in perceived competencies to develop exercise, weight loss, nutritional, and educational programs for overweight youth were found. GRIFFITHS, L. J. & PAGE, A. S. 2008. The impact of weight-related victimization on peer relationships: the female adolescent perspective. Obesity (Silver Spring), 16 Suppl 2, S39-45. Access of full text: http://www.ncbi.nlm.nih.gov/pubmed/18978762 Aim: Obesity is associated with undesirable psychological and social consequences. This qualitative study examined the relationship between obesity and victimization, and the impact this has on peer relationships. Conclusion: Weight-related victimization experiences were common and their impact on peer relationships was complex. Low self-confidence, isolation, and peer anxiety were all identified as resulting from victimization and were all barriers to developing peer relationships. Participants sought protection from victimization by seeking the "ideal" nonjudgmental empathetic best friend(s) and supportive family members to shield them from negative experiences. However there was also evidence that, while they were guarded with their own feelings, the experience of victimization increased empathy in these obese female adolescents. KRAIG, K. A. & KEEL, P. K. 2001. Weight-based stigmatization in children. Int J Obes Relat Metab Disord, 25, 1661-6. Access full text: http://www.nature.com/ijo/journal/v25/n11/full/0801813a.html Aim: To examine sex differences in children's weight-based stigmatization. DESIGN: Schoolbased sample of children evaluating qualities of children of varying weights. SUBJECTS: Thirtyfour children (age, 7-9 y; body mass index (BMI) 12.1-31.2 kg/m2). Conclusion: Children evaluated drawings of thin children most favorably and drawings of chubby children least favorably. Thin girls were rated more favorably than average or chubby girls, for whom ratings did not differ significantly. Conversely, chubby boys were rated less favorably than average or thin boys for whom ratings did not differ significantly. CONCLUSION: These patterns may further explain gender differences in motivation to lose weight. LATNER, J. D., SIMMONDS, M., ROSEWALL, J. K. & STUNKARD, A. J. 2007. Assessment of obesity stigmatization in children and adolescents: modernizing a standard measure. Obesity (Silver Spring), 15, 3078-85. Access full text: http://www.ncbi.nlm.nih.gov/pubmed/18198317 Aim: Stigmatization of overweight children is highly prevalent. However, the measurement of stigma has varied widely across studies. An up-to-date version of a commonly used measure of weight-related stigma is needed. scales (VASs). Conclusion: Rankings of liking of the new figures were highly correlated with rankings of corresponding old figures, especially for overweight figures [boys: rho (77) = 0.72, p < 0.001; girls: rho (153) = 0.68, p < 0.001]. Rankings of overweight and other figures were also highly correlated with VAS assessment of liking and with a composite, internally consistent VAS measure of liking and stereotypical attributes. Only negative stereotypes about the intelligence of overweight boys and girls contributed significantly to the variance in liking. Obesity Learning Centre Literature Update: Stigmatisation and obesity. February 2015 6 LATNER, J. D. & STUNKARD, A. J. 2003. Getting worse: the stigmatization of obese children. Obes Res, 11, 452-6. Access full text: http://www.ncbi.nlm.nih.gov/pubmed/12634444 Aim: The prevalence of childhood obesity more than doubled in the period from 1961 to 2001. We replicated a 1961 study of stigma in childhood obesity to see what effect this increased prevalence has had on this stigma. Conclusion: Children in both the present and the 1961 study liked the drawing of the obese child least. The obese child was liked significantly less in the present study than in 1961 [KruskalWallis H(1) = 130.53, p < 0.001]. Girls liked the obese child less than boys did [H(1) = 5.23, p < 0.02]. Children ranked the healthy child highest and significantly higher than in 1961 [H(1) = 245.40, p < 0.001]. The difference in liking between the healthy and obese child was currently 40.8% greater than in 1961. LATNER, J. D., STUNKARD, A. J. & WILSON, G. T. 2005. Stigmatized students: age, sex, and ethnicity effects in the stigmatization of obesity. Obes Res, 13, 1226-31. Access full text: http://www.ncbi.nlm.nih.gov/pubmed/16076992 Aim: To assess the stigmatization of obesity relative to the stigmatization of various disabilities among young men and women. Attitudes across ethnic groups were compared. In addition, these findings were compared with data showing severe stigmatization of obesity among children. Conclusion: Obesity was highly stigmatized relative to physical disabilities. African-American women liked obese peers more than did African-American men, white men, or white women [F(1,216) = 4.02, p < 0.05]. Overweight and obese participants were no less stigmatizing of obesity than normal weight participants. Adults were more accepting than children of their obese peers [t(761) = 9.16, p < 0.001]. MUSHER-EIZENMAN, D. R., HOLUB, S. C., MILLER, A. B., GOLDSTEIN, S. E. & EDWARDS-LEEPER, L. 2004. Body size stigmatization in preschool children: the role of control attributions. J Pediatr Psychol, 29, 613-20. Access full text: http://jpepsy.oxfordjournals.org/content/29/8/613.full Aim: The current study assessed preschool-age children's control attributions for weight and the relationship of these attributions to attitudes and behavioral intentions toward children of different body sizes. Forty-two children (mean age = 5.2 years) were interviewed about the adjectives they attributed to figures of different sizes, their preference for size in playmates, and their beliefs about children's ability to control their own weight. Conclusion: Adjective ratings for obese figures were the most negative, with no differences found for thin and average figures; the heaviest figure was also chosen less often than other figures to be a playmate. Internal attributions of control for weight were related to less positive adjective ratings for the heavier figure but not to children's friendship selections. Obesity Learning Centre Literature Update: Stigmatisation and obesity. February 2015 7 TUCCI, S. A., BOYLAND, E. J., HALFORD, J. C. & HARROLD, J. A. 2013. Stigmatisation of a formerly obese young female. Obes Facts, 6, 433-42. Access full text: http://www.ncbi.nlm.nih.gov/pubmed/24107842 Aim: Weight loss does not necessarily decrease the negative appraisal of a formerly overweight individual. Since past weight history tends to be disclosed in several contexts, this study aims to investigate whether negative appraisals are gender-specific and if they are modulated by the evaluators' own BMI. Conclusion: Female evaluators rated the target with the OW statement more negatively than the target with the NW statement. In contrast, males exposed to the OW statement rated the target as having fewer emotional/psychological problems and being less stupid/uncreative. BMI only influenced ratings in males, where those with higher BMI ascribed more negative attributes to the target with the NW statement than the OW statement. ZELLER, M. H., INGERSKI, L. M., WILSON, L. & MODI, A. C. 2010. Factors contributing to weight misperception in obese children presenting for intervention. Clin Pediatr (Phila), 49, 330-6. Access full text: http://www.ncbi.nlm.nih.gov/pubmed/20075030 Aim: To assess weight stigma, self-perception of weight status, and factors contributing to accurate self-perception of weight status in obese youth presenting for treatment at a hospital-based multidisciplinary weight management program. Conclusion: The majority endorsed negative/stereotypical attributes toward an obese body type, chose an average or underweight figure as their ideal, and 39% misperceived their weight status. Older child age and greater HRQOL impairment were significant predictors (P < .01) of correct self-perception. Pediatricians may find that talking with the elementary schoolaged patient and family about whether weight/size affects their day-to-day life will prove to be a salient and neutral opening to discussing the child's obesity and need for intervention. VAN DEN BERG, P., NEUMARK-SZTAINER, D., EISENBERG, M. E. & HAINES, J. 2008. Racial/ethnic differences in weight-related teasing in adolescents. Obesity (Silver Spring), 16 Suppl 2, S3-10. Access full text: http://www.ncbi.nlm.nih.gov/pubmed/18978760 Aim: The current study examined general, peer, and family weight teasing across race/ethnicity and weight status (average weight, overweight, obese) in adolescents. For those participants who reported peer or family weight teasing, the extent to which this teasing bothered them was also reported. Conclusions: Prevalences of general weight teasing were similar across race/ethnicity. AsianAmerican boys, black boys, and Asian-American girls reported lower prevalences of peer teasing than whites. Hispanic, Asian-American, and mixed/other girls reported higher prevalences of family weight teasing than did white girls. In nearly all racial/ethnic groups for all three teasing variables, obese adolescents were significantly more likely to report having been teased, compared to average-weight adolescents. In some racial/ethnic groups overweight adolescents were also significantly more likely than average-weight adolescents to report having been teased. Among girls who were teased, fewer black and mixed/other girls were bothered by peer teasing, compared to white girls. Similarly, fewer girls from most racial/ethnic groups were bothered by family weight teasing, compared to white girls. Obesity Learning Centre Literature Update: Stigmatisation and obesity. February 2015 8 Obesity and stigmatisation in health and care settings BLEICH, S. N., GUDZUNE, K. A., BENNETT, W. L., JARLENSKI, M. P. & COOPER, L. A. 2013. How does physician BMI impact patient trust and perceived stigma? Prev Med, 57, 120-4. Access full text: http://www.sciencedirect.com/science/article/pii/S0091743513001503 Aim: The objective is to evaluate whether physician body mass index (BMI) impacts their patients' trust or perceptions of weight-related stigma. Conclusion Patients reported high levels of trust in their PCPs, regardless of the PCPs body weight (normal BMI=8.6; overweight=8.3; obese=8.2; where 10 is the highest). Trust in diet advice was significantly higher among patients seeing overweight PCPs as compared to normal BMI PCPs (87% vs. 77%, p=0.04). Reports of feeling judged by their PCP were significantly higher among patients seeing obese PCPs (32%; 95% confidence interval (CI): 23-41) as compared to patients seeing normal BMI PCPs (14%; 95% CI: 7-20). Overweight and obese patients generally trust their PCP, but they more strongly trust diet advice from overweight PCPs as compared to normal BMI PCPs. COHEN, L. P., DANIEL, P.; STEADMANN, CATHERINE 2005. The O Word: Why the focus on obesity is harmful to community health. Californian Journal of Health Promotion, 33 Access full text: http://www.preventioninstitute.org/component/jlibrary/article/id-66/127.html Focusing on the obese and overweight individual alone and is not helping us address the broader social and economic issues that influence people’s lives. This paper discusses strategies to remove us from a focus on the O word and from blaming the individual for their condition. FERRANTE, J. M., PIASECKI, A. K., OHMAN-STRICKLAND, P. A. & CRABTREE, B. F. 2009. Family physicians' practices and attitudes regarding care of extremely obese patients. Obesity (Silver Spring), 17, 1710-6. Access full text: http://www.ncbi.nlm.nih.gov/pubmed/19282824 Aim: Despite the growing epidemic of extreme obesity in the United States, weight management is not adequately addressed in primary care. This study assessed family physicians' practices and attitudes regarding care of extremely obese patients and factors associated with them. Conclusion: Bariatric surgery and weight loss medications were infrequently recommended, particularly in physicians with higher volume of extremely obese patients (odds ratio (OR) 0.38; 95% confidence interval (CI) 0.23, 0.62 and OR 0.51; 95% CI 0.31, 0.85 for surgery and medications, respectively). Higher knowledge was associated with increased frequency of recommendations of weight loss medications (P < 0.0001) and bariatric surgery (P < 0.0001). There was a high prevalence of negative attitudes, particularly in younger physicians and those with lower patient volume. Increased knowledge of weight-loss diets was associated with less dislike in discussing weight loss (P < 0.0001), less frustration (P = 0.0001), less belief that treatment is often ineffective (P < 0.0001), and less pessimism about patient success (P = 0.0002). Many providers encountered challenges performing examinations on extremely obese Obesity Learning Centre Literature Update: Stigmatisation and obesity. February 2015 9 patients. More education of primary care physicians, particularly on bariatric surgery, specific examination techniques, and availability of community resources for obese persons is needed. Further research is needed to determine if interventions to increase knowledge of physicians will lead to less negative attitudes toward weight loss and extremely obese patients. FRIEDMAN, K. E., ASHMORE, J. A. & APPLEGATE, K. L. 2008. Recent experiences of weight based stigmatization in a weight loss surgery population: psychological and behavioral correlates. Obesity (Silver Spring), 16 Suppl 2, S69-74. Access full text: http://www.ncbi.nlm.nih.gov/pubmed/18978766 Aim: This study evaluated the association between experiences of weight-based stigmatization (e.g., job discrimination, inappropriate comments from physicians) within the past month, psychological functioning, and binge eating among a sample of individuals seeking weight loss surgery. Conclusion: Weight-based stigmatization was a common experience within the past month among participants. Frequency of stigmatizing experiences was negatively associated with self-esteem and positively associated with depression, anxiety, body image disturbance, and emotional eating. Recent experiences of stigmatization were associated with a diagnosis of binge eating disorder. Weight-based stigmatization is a common experience among obese individuals seeking weight loss surgery, and these experiences are associated with deleterious consequences. It appears that environmental barriers (e.g., chairs too small, not being able to find medical equipment in an appropriate size) and interpersonal attacks are the most common stigmatizing experiences. These data justify future studies to better understand causal relationships and efforts to design and test interventions aimed at reducing weight-based stigmatization and the associated negative consequences. KUSHNER, R. F., ZEISS, D. M., FEINGLASS, J. M. & YELEN, M. 2014. An obesity educational intervention for medical students addressing weight bias and communication skills using standardized patients. BMC Med Educ, 14, 53. Access full text: http://www.biomedcentral.com/1472-6920/14/53 Aim: In order to manage the increasing worldwide problem of obesity, medical students will need to acquire the knowledge and skills necessary to assess and counsel patients with obesity. Few educational intervention studies have been conducted with medical students addressing stigma and communication skills with patients who are overweight or obese. The purpose of this study was to evaluate changes in students' attitudes and beliefs about obesity, and their confidence in communication skills after a structured educational intervention that included a clinical encounter with an overweight standardized patient (SP). Conclusion: Three scales emerged from the questionnaire: negative obesity stereotyping (7 items), empathy (3 items), and counseling confidence (3 items). There were small but significant immediate post-intervention improvements in stereotyping (p = .002) and empathy (p < .0001) and a very large mean improvement in confidence (p < .0001). Significant improvement between baseline and immediate follow-up responses were maintained for empathy and counseling at one year after the encounter but stereotyping reverted to the baseline mean. Percent of students with improved scale scores immediately and at one year follow up were as follows: stereotyping 53.1% and 57.8%; empathy 48.4% and 47.7%; and confidence 86.7% and 85.9%. Obesity Learning Centre Literature Update: Stigmatisation and obesity. February 2015 10 MAGLIOCCA, K. R., JABERO, M. F., ALTO, D. L. & MAGLIOCCA, J. F. 2005. Knowledge, beliefs, and attitudes of dental and dental hygiene students toward obesity. J Dent Educ, 69, 1332-9. Access full text: http://www.ncbi.nlm.nih.gov/pubmed/16352769 Aim: Obesity is recognized as a growing public health problem. The authors surveyed dental hygiene and dental students from one institution regarding education, knowledge, perceived professional duties, and attitudes toward the overweight and obese population. Conclusion: Half of the respondents reported no obesity education prior to professional dental education, and 80 percent received five hours or less while in professional training. While most students held a generally positive attitude regarding obese and overweight patients, a number of students demonstrated evidence of negative stereotyping. Obesity education and training must be integrated into dental education to permit greater understanding of coexisting medical problems, explore the basis for a negative attitude and work toward its elimination, and raise public health awareness within dentistry. MULHERIN, K., MILLER, Y. D., BARLOW, F. K., DIEDRICHS, P. C. & THOMPSON, R. 2013. Weight stigma in maternity care: women's experiences and care providers' attitudes. BMC Pregnancy Childbirth, 13, 19. Access full text: http://www.biomedcentral.com/1471-2393/13/19 Aim: Weight stigma is pervasive in Western society and in healthcare settings, and has a negative impact on victims' psychological and physical health. In the context of an increasing focus on the management of overweight and obese women during and after pregnancy in research and clinical practice, the current studies aimed to examine the presence of weight stigma in maternity care. Addressing previous limitations in the weight stigma literature, this paper quantitatively explores the presence of weight stigma from both patient and care provider perspectives. Conclusion: Women with a higher BMI were more likely to report negative experiences of care during pregnancy and after birth, compared to lower weight women. Pre-service maternity care providers perceived overweight and obese women as having poorer self-management behaviours, and reported less positive attitudes towards caring for overweight or obese pregnant women, than normal-weight pregnant women. Even care providers who reported few weight stigmatising attitudes responded less positively to overweight and obese pregnant women. PERSKY, S. & ECCLESTON, C. P. 2011. Medical student bias and care recommendations for an obese versus non-obese virtual patient. Int J Obes (Lond), 35, 728-35. Access full text: http://www.ncbi.nlm.nih.gov/pubmed/20820169 Aim: This study examined the independent effect of a patient's weight on medical students' attitudes, beliefs and interpersonal behavior toward the patient, in addition to the clinical recommendations they make for her care. Conclusion: Analyses revealed more negative stereotyping, less anticipated patient adherence, worse perceived health, more responsibility attributed for potentially weightrelated presenting complaints and less visual contact directed toward the obese version of a virtual patient than the non-obese version of the patient. In contrast, there was no clear evidence of bias in clinical recommendations made for the patient's care. Obesity Learning Centre Literature Update: Stigmatisation and obesity. February 2015 11 SARWER, D. B., FABRICATORE, A. N., EISENBERG, M. H., SYWULAK, L. A. & WADDEN, T. A. 2008. Self-reported stigmatization among candidates for bariatric surgery. Obesity (Silver Spring), 16 Suppl 2, S75-9. Access full text: http://www.ncbi.nlm.nih.gov/pubmed/18978767 Aim: The popularity of bariatric surgery has increased the focus on the psychological aspects of extreme obesity. Although a growing literature has documented the psychosocial burden associated with extreme obesity, surprisingly little attention has been paid to the experience of weight-related stigmatization among extremely obese individuals. The present study investigated self-reported experiences of weight-related stigmatization, weight-related quality of life, and depressive symptoms among 117 extremely obese individuals (BMI = 48.2 +/- 7.5 kg/m2) who presented for bariatric surgery at the Hospital of the University of Pennsylvania. Conclusion: In general, these individuals reported infrequent weight-related stigma, which was unrelated to BMI. Some specific forms of stigmatization, however, appear to be related to body size. The occurrence of stigmatization was associated with poorer weight-related quality of life and greater symptoms of depression. SCHWARTZ, M. B., CHAMBLISS, H. O., BROWNELL, K. D., BLAIR, S. N. & BILLINGTON, C. 2003. Weight bias among health professionals specializing in obesity. Obes Res, 11, 1033-9. Access full text: http://www.ncbi.nlm.nih.gov/pubmed/12972672 Aim: To determine the level of anti-fat bias in health professionals specializing in obesity and identify personal characteristics that correlate with both implicit and explicit bias. Conclusion: Health professionals exhibited a significant pro-thin, anti-fat implicit bias on the IAT. In addition, the subjects significantly endorsed the implicit stereotypes of lazy, stupid, and worthless using the IAT. Level of bias was associated with several personal characteristics. Characteristics significantly predictive of lower levels of implicit anti-fat bias include being male, older, having a positive emotional outlook on life, weighing more, having friends who are obese, and indicating an understanding of the experience of obesity. SIKORSKI, C., LUPPA, M., GLAESMER, H., BRAHLER, E., KONIG, H. H. & RIEDEL-HELLER, S. G. 2013. Attitudes of health care professionals towards female obese patients. Obes Facts, 6, 512-22. Access full text: http://www.ncbi.nlm.nih.gov/pubmed/24296724 Aim: The health care setting has been reported to be one main source of weight stigma repeatedly; however, studies comparing different professions have been lacking. Conclusion: Only 25% graded current health care of obese patients to be 'good' or 'very good'. 63% of all HCPs 'somewhat' or 'strongly' agreed that it was often difficult to get the resources needed in order to care for obese patients. The mean FPS score was comparable to that in the general public (M = 3.59), while nursing staff showed slightly more positive attitudes compared to physicians and therapists. Higher age, higher BMI, and ascribing personal responsibility for obesity to the individual were associated with a higher level of stigmatizing attitudes. The nursing staff agreed on obesity as an illness to a greater extent while physicians attributed obesity to the individual. Obesity Learning Centre Literature Update: Stigmatisation and obesity. February 2015 12 SWIFT, J. A., TISCHLER, V., MARKHAM, S., GUNNING, I., GLAZEBROOK, C., BEER, C. & PUHL, R. 2013. Are anti-stigma films a useful strategy for reducing weight bias among trainee healthcare professionals? Results of a pilot randomized control trial. Obes Facts, 6, 91-102. Access full text: http://www.ncbi.nlm.nih.gov/pubmed/23466551 Aim: Weight bias is an important clinical issue that the educators of tomorrow's healthcare professionals cannot afford to ignore. This study, therefore, aimed to pilot a randomized controlled trial of the effects of educational films designed to reduce weight stigmatization toward obese patients on trainee dietitians' and doctors' attitudes. Conclusion: The current study suggests both that it is possible to conduct a substantive trial of the effects of educational films designed to reduce weight stigma on a larger cohort of trainee healthcare professionals, and that brief educational interventions may be effective in reducing stigmatizing attitudes in this population. TEACHMAN, B. A. & BROWNELL, K. D. 2001. Implicit anti-fat bias among health professionals: is anyone immune? Int J Obes Relat Metab Disord, 25, 1525-31. Access to full text: http://www.ncbi.nlm.nih.gov/pubmed/11673776 Aim: To investigate whether negative implicit attitudes and beliefs toward overweight persons exist among health professionals who specialize in obesity treatment, and to compare these findings to the implicit anti-fat bias evident in the general population. Conclusion: Clear evidence for implicit anti-fat bias was found for both the attitude and stereotype measures. As expected, this bias was strong but was lower than bias in the general population. Also as predicted, only minimal evidence for an explicit anti-fat bias was found. Implicit and explicit measures of the lazy stereotype were positively related although the attitude measures were not. Public perceptions of and attitudes towards obesity HAYDEN, M. J., DIXON, M. E., DIXON, J. B., PLAYFAIR, J. & O'BRIEN, P. E. 2010. Perceived discrimination and stigmatisation against severely obese women: age and weight loss make a difference. Obes Facts, 3, 7-14. Access full text: http://www.ncbi.nlm.nih.gov/pubmed/20215790 Aim: Patients' perceptions about weight-related stigma and discrimination were assessed in 2 groups of patients, obese and laparoscopic adjustable gastric banding (LAGB). Conclusion: Whilst perceptions of discrimination and stigmatisation were common and affected many life situations, they were less prevalent than previous reports. It appeared that it was not the frequency or number of events which affected an individual but the intensity of the experience. Younger women reported greater discrimination than older women and felt the social consequences of obesity to a greater extent. Older women were more concerned about the consequences of being overweight on their health. Obesity Learning Centre Literature Update: Stigmatisation and obesity. February 2015 13 HEBL, M. R., RUGGS, E. N., SINGLETARY, S. L. & BEAL, D. J. 2008. Perceptions of obesity across the lifespan. Obesity (Silver Spring), 16 Suppl 2, S46-52. Access full text: http://www.ncbi.nlm.nih.gov/pubmed/18978763 Aim: Previous research on obesity stereotyping has almost extensively involved looking at the perceptions that 5-21-year-old individuals have toward members of their own age in-group. Very little research has examined how people perceive obesity across the lifespan. The current research begins to address this gap by examining the extent to which individuals between 18 and 77 years of age stereotype obesity in 20, 40, and 60-year-old targets. Conclusion: As predicted, heavier women were rated more negatively than thinner women on every dimension we examined. In addition, older women were rated more negatively than younger women on attractiveness, but more positively on every other dimension. Other main effects revealed that female (relative to male) and older (relative to younger) participants were more lenient in their ratings. Several two-way interactions revealed that the obesity stereotype for attractiveness is exaggerated when targets are younger, that males (compared to females) levy a greater penalty for increasing weight, and that this pattern is exaggerated more for younger men. DISCUSSION: This research shows a consistency across the lifespan in the extent to which participants, varying in weight, age, and sex, stereotype obesity. It also appears that, at least with respect to attractiveness, younger obese individuals are denigrated to a larger degree than older. In sum, this research shows prevalent and consistent patterns of obesity stereotyping across the lifespan. HILBERT, A., RIEF, W. & BRAEHLER, E. 2008. Stigmatizing attitudes toward obesity in a representative population-based sample. Obesity (Silver Spring), 16, 1529-34. Access full text: http://onlinelibrary.wiley.com/doi/10.1038/oby.2008.263/full Aim: The aim of this study was to determine stigmatizing attitudes toward obesity in the population, and its related psychological and sociodemographic determinants. Conclusion: Of the 1,000 participants, 23.5% (n=235) had stigmatizing attitudes toward obesity, 21.5% (n=215) did not have stigmatizing attitudes toward obesity, and 55.0% (n=550) had attitudes that were undetermined with respect to stigmatization. Predictors of greater stigmatization were more causal attributions of obesity to individual behavior, less education, and older age, while causal attributions of obesity to heredity and labeling obesity as an illness predicted less stigmatization. Stigmatizing attitudes were significantly associated with stronger overall support of obesity prevention, but less readiness to support prevention financially. LIEBERMAN, D. L., TYBUR, J. M. & LATNER, J. D. 2012. Disgust sensitivity, obesity stigma, and gender: contamination psychology predicts weight bias for women, not men. Obesity (Silver Spring), 20, 1803-14. Access full text: http://www.ncbi.nlm.nih.gov/pubmed/21836644 Recent research has established a link between disgust sensitivity and stigmatizing reactions to various groups, including obese individuals. However, previous research has overlooked disgust's multiple evolved functions. Here, we investigated whether the link between disgust sensitivity and obesity stigma is specific to pathogen disgust, or whether sexual disgust and moral disgust--two separate functional domains--also relate to negative attitudes toward obese individuals. Additionally, we investigated whether sex differences exist in the manner disgust sensitivity predicts obesity stigma, whether the sexes differ across the subtypes of obesity bias independent of disgust sensitivity, and last, the association between participants' BMI and different subtypes of obesity stigma. In study 1 (N = 92), we established that obesity elicits pathogen, sexual, and moral disgust. In study 2, we investigated the relationship Obesity Learning Centre Literature Update: Stigmatisation and obesity. February 2015 14 between these types of disgust sensitivity and obesity stigma. Participants (N = 387) reported their level of disgust toward various pathogen, sexual, and moral acts and their attitudes toward obese individuals. For women, but not men, increased pathogen disgust sensitivity predicted more negative attitudes toward obese individuals. Men reported more negative general attitudes toward obese individuals whereas women reported greater fear of becoming obese. The sexes also differed in how their own BMI related to the subtypes of obesity stigma. These findings indicate that pathogen disgust sensitivity plays a role in obesity stigma, specifically for women. Defining the scope of disgust's activation in response to obesity and its relationship with other variables can help identify possible mechanisms for understanding and ultimately alleviating prejudice and discrimination. LIPPA, N. C. & SANDERSON, S. C. 2012. Impact of information about obesity genomics on the stigmatization of overweight individuals: an experimental study. Obesity (Silver Spring, Md.) [Online], 20. Access full text: http://www.ncbi.nlm.nih.gov/pubmed/22673191 Advances in genomic technologies are rapidly leading to new understandings of the roles that genetic variations play in obesity. Increasing public dissemination of information regarding the role of genetics in obesity could have beneficial, harmful, or neutral effects on the stigmatization of obese individuals. This study used an online survey and experimental design to examine the impact of genetic versus non-genetic information on obesity stigma among selfperceived non-overweight individuals. Participants (n = 396) were randomly assigned to read either genetic, non-genetic (environment), or gene-environment interaction obesity causal information. A total of 48% of participants were female; mean age was 42.7 years (range = 1886 years); 75% were white; 45.2% had an annual household income of less than $40,000; mean BMI was 23.4 kg/m(2). Obesity stigma was measured using the Fat Phobia Scale - short form (FPS-S). After reading the experimental information, participants in the genetic and geneenvironment conditions were more likely to believe that genetics increase obesity risk than participants in the non-genetic condition (both P < 0.05), but did not differ on obesity stigma. Obesity stigma was higher among whites and Asians than Hispanics and African Americans (P = 0.029), and associated with low self-esteem (P = 0.036). Obesity stigma was also negatively associated with holding 'germ or virus' (P = 0.033) and 'overwork' (P = 0.016) causal beliefs about obesity, and positively associated with 'diet or eating habits' (P = 0.001) and 'lack of exercise' (P = 0.004) causal beliefs. Dissemination of brief information about the role of genetics in obesity may have neither a beneficial nor a harmful impact on obesity stigmatization compared with non-genetic information among self-perceived non-overweight individuals. O'BRIEN, K. S., LATNER, J. D., HALBERSTADT, J., HUNTER, J. A., ANDERSON, J. & CAPUTI, P. 2008. Do antifat attitudes predict antifat behaviors? Obesity (Silver Spring), 16 Suppl 2, S87-92. Access full text: http://www.ncbi.nlm.nih.gov/pubmed/18978769 Aim: The aim of this study was to investigate discrimination against obese job candidates, and to examine whether widely used measures of implicit and explicit antifat attitudes are related to or predict antifat discrimination. Conclusion: Participants rated obese job candidates as having less leadership potential, as less likely to succeed, and as less likely to be employed than normal-weight candidates. Obese candidates were also given a lower starting salary and ranked as less qualified overall than candidates portrayed as normal weight. Neither implicit nor explicit antifat attitude measures were significantly related to antifat discrimination. Obesity Learning Centre Literature Update: Stigmatisation and obesity. February 2015 15 SIKORSKI, C., LUPPA, M., BRAHLER, E., KONIG, H. H. & RIEDEL-HELLER, S. G. 2012. Obese children, adults and senior citizens in the eyes of the general public: results of a representative study on stigma and causation of obesity. PLoS One, 7, e46924. Access full text: http://www.ncbi.nlm.nih.gov/pubmed/23071664 Obese individuals are blamed for their excess weight based on causal attribution to the individual. It is unclear whether obese individuals of different age groups and gender are faced with the same amount of stigmatization. This information is important in order to identify groups of individuals at risk for higher stigmatization and discrimination. A telephone interview was conducted in a representative sample of 3,003 participants. Experimental manipulation was realized by vignettes describing obese and normal-weight children, adults and senior citizens. Stigmatizing attitudes were measured by semantic differential. Causal attribution was assessed. Internal factors were rated with highest agreement rates as a cause for the vignette's obesity. Lack of activity behavior and eating too much are the most supported causes. Importance of causes differed for the different vignettes. For the child, external causes were considered more important. The overweight vignette was rated consistently more negatively. Higher educational attainment and personal obesity were associated with lower stigmatizing attitudes. The vignette of the obese child was rated more negatively compared to that of an adult or senior citizen. Obesity is seen as a controllable condition, but for children external factors are seen as well. Despite this finding, they are faced with higher stigmatizing attitudes in the general public, contradicting attribution theory assumptions. Internal and external attribution were found to be inter-correlated. Obese children are the population most at risk for being confronted with stigmatization, making them a target point in stigma-reduction campaigns. SIKORSKI, C., LUPPA, M., KAISER, M., GLAESMER, H., SCHOMERUS, G., KONIG, H. H. & RIEDELHELLER, S. G. 2011. The stigma of obesity in the general public and its implications for public health - a systematic review. BMC Public Health, 11, 661. Access full text: http://www.biomedcentral.com/1471-2458/11/661 Aim: Up to this date, prevalence rates of obesity are still rising. Aside from co-morbid diseases, perceived discrimination and stigmatization leads to worsen outcomes in obese individuals. Higher stigmatizing attitudes towards obese individuals may also result in less support of preventive and interventive measures. In light of the immense burden of obesity on health care systems and also on the individuals' quality of life, accepted and subsidized preventive measures are needed. Policy support might be determined by views of the lay public on causes of obesity and resulting weight stigma. This study seeks to answer how representative samples of the lay public perceive people with obesity or overweight status (stigmatizing attitudes); what these samples attribute obesity to (causal attribution) and what types of interventions are supported by the lay public and which factors determine that support (prevention support). Conclusion: Only 7 articles were found. One study reported prevalence rates of stigmatizing attitudes. About a quarter of the population in Germany displayed definite stigmatizing attitudes. Other studies reported causal attributions. While external influences on weight are considered as well, it seems that internal factors are rated to be of higher importance. Across the studies found, regulative prevention is supported by about half of the population, while childhood prevention has highest approval rates. Results on sociodemographic determinants differ substantially. Obesity Learning Centre Literature Update: Stigmatisation and obesity. February 2015 16 VARTANIAN, L. R. 2010. Disgust and perceived control in attitudes toward obese people. Int J Obes (Lond), 34, 1302-7. Access full text: http://www.ncbi.nlm.nih.gov/pubmed/20195287 Aim: Efforts to explain negative attitudes toward obese people have centered on beliefs about the controllability of body weight, whereas other processes (such as the emotion of disgust) have been largely ignored. This study examined the role of disgust in evaluations of obese people, as well as other social groups (for example smokers, drug addicts, women, homosexuals, politicians). Conclusion: Disgust was the strongest predictor of negative attitudes toward obese people, and disgust fully mediated the association between perceptions of control and attitudes toward obese people. In addition, obese people were rated less favorably, and as more disgusting, than almost all social groups. Across all social groups, perceived control over group membership was positively correlated with disgust ratings, and disgust mediated the link between perceived control and favorability ratings. Stigmatization of and discrimination against obese individuals in the workplace GIEL, K. E., ZIPFEL, S., ALIZADEH, M., SCHAFFELER, N., ZAHN, C., WESSEL, D., HESSE, F. W., THIEL, S. & THIEL, A. 2012. Stigmatization of obese individuals by human resource professionals: an experimental study. BMC Public Health, 12, 525. Access full text: http://www.biomedcentral.com/1471-2458/12/525 Aim: Weight-related stigmatization is a public health problem. It impairs the psychological wellbeing of obese individuals and hinders them from adopting weight-loss behaviors. We conducted an experimental study to investigate weight stigmatization in work settings using a sample of experienced human resource (HR) professionals from a real-life employment setting. Conclusion: Participants underestimated the occupational prestige of obese individuals and overestimated it for normal-weight individuals. Obese people were more often disqualified from being hired and less often nominated for a supervisory position, while non-ethnic normalweight individuals were favored. Stigmatization was most pronounced in obese females. GIEL, K. E., THIEL, A., TEUFEL, M., MAYER, J. & ZIPFEL, S. 2010. Weight bias in work settings - a qualitative review. Obes Facts, 3, 33-40. Access full text: http://www.ncbi.nlm.nih.gov/pubmed/20215793 Aim: Studies have repeatedly demonstrated the influence of physical appearance on behavior and treatment of individuals in work settings. A high proportion of obese individuals in the USA have reported perceived discrimination in the work place due to their body weight. The present review examines the specific kind, context and extent of a weight bias in work settings. Conclusion: There is evidence from self-report data, surveys, and laboratory research for a weight bias in five aspects of work life. Evidence shows that obesity is a general barrier to employment, certain professions and professional success. Obese individuals are at higher risk of encountering stereotypes concerning their work-related qualities and for general unequal Obesity Learning Centre Literature Update: Stigmatisation and obesity. February 2015 17 treatment in the work place. Current evidence reveals a weight bias in several areas in the work place. The ecological validity of results is limited due to the predominant reliance on laboratory studies with student samples. Field studies are needed to examine weight-based discrimination in actual work environments as well as to uncover underlying mechanisms. MILLER, B. J. & LUNDGREN, J. D. 2010. An experimental study of the role of weight bias in candidate evaluation. Obesity (Silver Spring), 18, 712-8. Access full text: http://www.ncbi.nlm.nih.gov/pubmed/20111025 Obese individuals are evaluated negatively and attributed negative trait characteristics in several contexts including employment, health care, and education. The current experimental study of college students examined the effect of body mass on the evaluation of political candidates and examined whether the gender of the candidate moderated the relationship. A series of ordinary least squares regression analyses found an interactive effect between candidate obesity and candidate gender for global evaluation and for several trait characteristics. Specifically, obese female candidates were evaluated more negatively than nonobese female candidates and nonobese male candidates were evaluated more negatively than were obese male candidates. This interaction persisted even after controlling for standard political and demographic characteristics of the evaluator. These findings suggest that weight bias exists for obese female political candidates, but that larger body size may be an asset for male candidates. The ability of candidates to be successful may depend less on their policy positions or even party affiliation and more on their physical attributes than has been previously assumed. Portrayals of obesity in the media GREENBERG, B. S., EASTIN, M., HOFSCHIRE, L., LACHLAN, K. & BROWNELL, K. D. 2003. Portrayals of overweight and obese individuals on commercial television. Am J Public Health, 93, 1342-8. Access full text: http://www.ncbi.nlm.nih.gov/pubmed/12893625 Aim: This study examined the distribution and individual characteristics of body types on primetime television. Conclusion: Of 1018 major television characters, 14% of females and 24% of males were overweight or obese, less than half their percentages in the general population. Overweight and obese females were less likely to be considered attractive, to interact with romantic partners, or to display physical affection. Overweight and obese males were less likely to interact with romantic partners and friends or to talk about dating and were more likely to be shown eating. HILBERT, A. & RIED, J. 2009. Obesity in print: an analysis of daily newspapers. Obes Facts, 2, 4651. Access full text: http://www.ncbi.nlm.nih.gov/pubmed/20054204 Aim: Stigmatizing attitudes towards obese people are common in the public. Based on findings that portrayals of obesity in entertainment media foster weight-related stigmatization, the goal of the current study was to analyze media coverage of obesity in daily newspapers. Conclusion: The national and local newspapers examined offered more comprehensive and Obesity Learning Centre Literature Update: Stigmatisation and obesity. February 2015 18 less incorrect information about obesity than the tabloid newspaper. Compared with the other types of papers, the information about obesity in the local papers was less negative and less catastrophizing. The national newspapers presented more attributions of obesity to internal, controllable causes than the other newspaper types, and the tabloid newspaper used more personalized descriptions of cases with extreme features. Effect of stigmatization CARELS, R. A., DOMOFF, S. E., BURMEISTER, J. M., KOBALL, A. M., HINMAN, N. G., DAVIS, A. K., WAGNER OEHLHOF, M., LEROY, M., BANNON, E. & HOFFMANN, D. A. 2013. Examining perceived stereotype threat among overweight/obese adults using a multi-threat framework. Obes Facts, 6, 258-68. Access full text: http://www.ncbi.nlm.nih.gov/pubmed/23736227 Aim: The Multi-Threat Framework accounts for potentially different forms of stereotype threat that differ in target (i.e., the individual or the group) and source (i.e., the self or others). This investigation examined how these different forms of perceived stereotype threat were related to concepts, such as group identity, stereotype endorsement, stigma consciousness, etc., among overweight and obese individuals. Conclusion: Participants reported a history of feeling threatened by stereotypes related to weight. When reflecting on past experiences of perceived stereotype threat, participants reported greater levels of self/own stereotype threat compared to group stereotype threat. Level of stereotype threat was related to a number of personal characteristics (i.e., sex, BMI) and individual factors (i.e., group identity, stigma consciousness, fear of fat). Individuals who are overweight report a history of being threatened by negative stereotypes. The findings support the Multi-Threat Framework for stereotype threat based on body weight. Overweight individuals' susceptibility to stereotype threat may vary systematically depending on several factors. Future research should examine weight-related stereotypes' impact on cognitive and behavioral outcomes. CARR, D. & JAFFE, K. 2012. The psychological consequences of weight change trajectories: evidence from quantitative and qualitative data. Econ Hum Biol, 10, 419-30. Access full text: http://www.ncbi.nlm.nih.gov/pubmed/22580044 We use quantitative and qualitative data to explore the psychological impact of weight change among American adults. Using data from the Midlife Development in the United States (MIDUS) study, a survey of more than 3000 adults ages 25-74 in 1995, we contrast underweight, normal weight, overweight, obese I, and obese II/III persons along five psychosocial outcomes: positive mood, negative mood, perceived interpersonal discrimination, self-acceptance, and self-satisfaction. We further assess whether these relationships are contingent upon one's body mass index (BMI) at age 21. We find a strong inverse association between adult BMI and each of the five outcomes, reflecting the stigma associated with high body weight. However, overweight adults who were also overweight at age 21 are more likely than persons who were previously slender to say they were "very satisfied" with themselves. Results from 40 in-depth semi-structured interviews reveal similarly that persons who were persistently overweight or obese accept their weight as part of their identity, whereas those who experienced substantial weight increases (or decreases) struggle between two identities: the weight they actually are, and the weight that they believe Obesity Learning Centre Literature Update: Stigmatisation and obesity. February 2015 19 exemplifies who they are. We discuss implications for stigma theory, and the ways that stigma exits and entries affect psychological well-being. CARR, D., JAFFE, K. J. & FRIEDMAN, M. A. 2008. Perceived interpersonal mistreatment among obese Americans: do race, class, and gender matter? Obesity (Silver Spring), 16 Suppl 2, S60-8. Access full text: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2852250/ Aim: We examine the extent to which body weight affects three types of perceived interpersonal mistreatment, and evaluate whether these patterns vary by race, social class, and gender in a large sample of American men and women. Conclusion: In the total sample, obese I and obese II/III persons report significantly higher levels of all three types of perceived mistreatment (compared to normal weight persons), even when demographic, socioeconomic status, and health characteristics are controlled. Among black men, however, obese II/III persons report significantly lower levels of all three types of perceived mistreatment, compared to their normal weight peers. Among both men and women, obese professional workers report significantly more perceived interpersonal mistreatment, compared to obese persons of lower socioeconomic status. FRIEDMAN, K. E., REICHMANN, S. K., COSTANZO, P. R., ZELLI, A., ASHMORE, J. A. & MUSANTE, G. J. 2005. Weight stigmatization and ideological beliefs: relation to psychological functioning in obese adults. Obes Res, 13, 907-16. Access full text: http://www.ncbi.nlm.nih.gov/pubmed/15919845 Aim: This study evaluated the relation among weight-based stigmatization, ideological beliefs about weight, and psychological functioning in an obese, treatment-seeking sample. Conclusion: Weight-based stigmatization was a common experience for participants. Frequency of stigmatizing experiences was positively associated with depression, general psychiatric symptoms, and body image disturbance, and negatively associated with selfesteem. Further, participants' own negative attitudes about weight problems were associated with their psychological distress and moderated the relation between the experience of stigmatization and body image. OGDEN, J. C., CECELIA 2010. The experience of being obese and the many consequences of stigma. Journal of Obesity, 9. Access full text: http://www.hindawi.com/journals/jobe/2010/429098/ Aim: The present qualitative study aimed to explore how people experience their obesity and to explore the impact of this on their motivations to lose weight. Conclusion: Participants (n = 46) were either currently obese or had been obese and were interviewed about their experiences. Participants described the impact of obesity on aspects of their self-identity and used language such as “ugly”, “freak”, “hate”, “blob”, and “disgust” which reflected the pervasively negative impact of their weight. They highlighted a complex and often contradictory relationship with food and described how such negative experiences were created out of the dynamic between their obesity and a stigmatising social context. Some, however, suggested that such stigma could also have positive consequences by promoting and encouraging behaviour change. Many obese people, therefore, experience their weight in profoundly negative way as a result of existing within a social context which stigmatises their condition. The results are discussed in terms of the costs and benefits of stigma and a balance between support, tolerance, and collusion in promoting weight loss. Obesity Learning Centre Literature Update: Stigmatisation and obesity. February 2015 20 PUHL, R. 2009. Obesity stigma - Causes, effects and some practical solutions. Diabetes Voice, 54. Access full text: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2866597/ Obesity has become a pandemic, affecting adults and children around the world. Considerable medical, scientific and lifestyle-related knowledge and resources are being channelled into the identification of strategies to combat this major public health problem. Despite these multidisciplinary efforts, however, little attention has been paid to the damaging social and psychological consequences of obesity. Many people with overweight and/or obesity frequently face stigmatization, prejudice and discrimination because of their body size and shape, with disturbing and potentially harmful implications for their emotional and physical health and well-being. Given the high rates of type 2 diabetes among people with obesity, many of those with diabetes are vulnerable to weight stigma and its consequences. SUTIN, A. R. T., ANTONIO 2013. Perceived weight discrimination and obesity. PLoS One. Access full text: http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0070048 Aim: Weight discrimination is prevalent in American society. Although associated consistently with psychological and economic outcomes, less is known about whether weight discrimination is associated with longitudinal changes in obesity. The objectives of this research are (1) to test whether weight discrimination is associated with risk of becoming obese (Body Mass Index≥30; BMI) by follow-up among those not obese at baseline, and (2) to test whether weight discrimination is associated with risk of remaining obese at follow-up among those already obese at baseline. Participants were drawn from the Health and Retirement Study, a nationally representative longitudinal survey of community-dwelling US residents. A total of 6,157 participants (58.6% female) completed the discrimination measure and had weight and height available from the 2006 and 2010 assessments. Conclusion: Participants who experienced weight discrimination were approximately 2.5 times more likely to become obese by follow-up (OR = 2.54, 95% CI = 1.58–4.08) and participants who were obese at baseline were three times more likely to remain obese at follow up (OR = 3.20, 95% CI = 2.06–4.97) than those who had not experienced such discrimination. These effects held when controlling for demographic factors (age, sex, ethnicity, education) and when baseline BMI was included as a covariate. These effects were also specific to weight discrimination; other forms of discrimination (e.g., sex, race) were unrelated to risk of obesity at follow-up. The present research demonstrates that, in addition to poorer mental health outcomes, weight discrimination has implications for obesity. Rather than motivating individuals to lose weight, weight discrimination increases risk for obesity. STAMAN, J. 2007. Obesity discrimination and the Americans with Disabilities Act. Congressional Research Service Reports and Issue Briefs. Access full text: http://digitalcommons.ilr.cornell.edu/cgi/viewcontent.cgi?article=1025&context=crs The Americans with Disabilities Act (ADA) provides broad nondiscrimination protection for individuals with disabilities. However, to be covered under the statute, an individual must first meet the definition of an individual with a disability. Questions have been raised as to whether and to what extent obesity is a disability under the ADA and whether the ADA protects obese individuals from discrimination. This report provides background regarding how obesity is covered under the ADA and its supporting regulations. It also discusses some of the ways in Obesity Learning Centre Literature Update: Stigmatisation and obesity. February 2015 21 which courts have applied the ADA to obesity discrimination claims. WANG, S. S., BROWNELL, K. D. & WADDEN, T. A. 2004. The influence of the stigma of obesity on overweight individuals. Int J Obes Relat Metab Disord, 28, 1333-7. Access full text: http://www.nature.com/ijo/journal/v28/n10/abs/0802730a.html Aim: To investigate the internalization of anti-fat bias among overweight individuals across a variety of attitudes and stereotypes. Conclusion: Participants exhibited significant anti-fat bias on the IAT across several attributes and stereotypes. They also endorsed the explicit belief that fat people are lazier than thin people. Unlike other minority group members, overweight individuals do not appear to hold more favorable attitudes toward ingroup members. This ingroup devaluation has implications for changing the stigma of obesity and for understanding the psychosocial and even medical impact of obesity on those affected. Measuring stigmatization BACON, J. G., SCHELTEMA, K. E. & ROBINSON, B. E. 2001. Fat phobia scale revisited: the short form. Int J Obes Relat Metab Disord, 25, 252-7. Access full text: http://www.ncbi.nlm.nih.gov/pubmed/11410828 Aim: To develop a shortened form of the original 50-item fat phobia scale. Conclusion: The shortened fat phobia scale is expected to increase the utility of the measure in a diverse array of research and clinical settings. Future research should focus on developing scale norms for the general population and conducting research on fat phobia in males and among different ethnic groups. DEPIERRE, J. A. & PUHL, R. M. 2012. Experiences of weight stigmatization: a review of self-report assessment measures. Obes Facts, 5, 897-918. Access full text: http://www.ncbi.nlm.nih.gov/pubmed/23296154 Aim: Overweight and obese persons are vulnerable to frequent stigmatization and discrimination because of their weight. Despite widespread prejudice towards obese persons, many questions remain regarding the nature, extent, and impact of weight-based stigmatization experienced by so many people. However, improving our knowledge in this area will only be as good as the measures we have to study this phenomenon. Our paper is the first to provide a comprehensive summary of published quantitative self-report measures available for assessing experiences of weight stigmatization in children and adults. Conclusion: Existing measures contain a number of limitations and have been assessed in samples lacking diversity. Improvements in measurement are needed to achieve a clearer understanding of the nature and extent of self-perceived weight stigmatization and to develop measures that accurately reflect this type of stigmatization. Specific directions for future research that will help improve measurement of self-perceived weight stigmatization and advance this area of study are highlighted. Obesity Learning Centre Literature Update: Stigmatisation and obesity. February 2015 22 RUGGS, E. N., KING, E. B., HEBL, M. & FITZSIMMONS, M. 2010. Assessment of weight stigma. Obes Facts, 3, 60-9. Access full text: http://www.ncbi.nlm.nih.gov/pubmed/20215796 The purpose of this review article is to familiarize readers with the common methodologies used to assess weight stigma. This article explores the most frequent ways weight stigma is assessed, offers relevant empirical examples of each methodology, examines the strengths and weaknesses of each approach, and offers recommendations for strengthening research assessment of weight stigma for the future. Furthermore, this article highlights 4 dimensions that are important to consider when assessing weight stigma, regardless of the research methodology used. Self-perception and self-stigmatization in obese individuals BARBER, J. A., PALMESE, L., REUTENAUER, E. L., GRILO, C. M. & TEK, C. 2011. Implications of weight-based stigma and self-bias on quality of life among individuals with schizophrenia. J Nerv Ment Dis, 199, 431-5. Access full text: http://www.ncbi.nlm.nih.gov/pubmed/21716053 Aim: Obesity has been associated with significant stigma and weight-related self-bias in community and clinical studies, but these issues have not been studied among individuals with schizophrenia. A consecutive series of 70 obese individuals with schizophrenia or schizoaffective disorder underwent assessment for perceptions of weight-based stigmatization, self-directed weight bias, negative affect, medication compliance, and quality of life. The levels of weight-based stigmatization and self-bias were compared with levels reported for nonpsychiatric overweight/obese samples. Weight measures were unrelated to stigma, selfbias, affect, and quality of life. Weight-based stigmatization was lower than published levels for nonpsychiatric samples, whereas levels of weight-based self-bias did not differ. After controlling for negative affect, weight-based self-bias predicted an additional 11% of the variance in the quality of life measure. Individuals with schizophrenia and schizoaffective disorder reported weight-based self-bias to the same extent as nonpsychiatric samples despite reporting less weight stigma. Weight-based self-bias was associated with poorer quality of life after controlling for negative affect. CARELS, R. A., HINMAN, N., KOBALL, A., OEHLHOF, M. W., GUMBLE, A. & YOUNG, K. M. 2011. The self-protective nature of implicit identity and its relationship to weight bias and short-term weight loss. Obes Facts, 4, 278-83. Access full text: http://www.ncbi.nlm.nih.gov/pubmed/21921650 Aim: Research suggests that making overly positive self-evaluations is the norm rather than the exception. However, unlike other stigmatized groups, overweight individuals do not exhibit a positive in-group social identity and instead exhibit significant explicit, implicit, and internalized weight bias. Therefore, it is not known whether overweight/obese individuals will evidence selfenhancement on general traits (good, attractive), or on traits inconsistent with fat stereotypes (disciplined, active, healthy eater), on an assessment of implicit attitudes. Similarly, it is not known whether these ratings will be associated with preexisting levels of weight bias, gender, Obesity Learning Centre Literature Update: Stigmatisation and obesity. February 2015 23 or short-term weight loss. Conclusion: Although participants evidenced significant anti-fat attitudes, they implicitly identified themselves as significantly thinner, better, more attractive, active, disciplined, and more likely to eat healthy than 'other' people. Compared to men, women were less likely to view themselves as thin and attractive relative to others. Greater implicit anti-fat bias and implicitly seeing the self as thin relative to others was associated with less short-term weight loss. Despite evidence for explicit, implicit, and internalized weight bias, participants generally evidenced a positive implicit self-identity, including areas consistent with negative fat stereotypes. CARELS, R. A., HINMAN, N. G., BURMEISTER, J. M., HOFFMANN, D. A., ASHRAFIOUN, L. & KOBALL, A. M. 2013. Stereotypical images and implicit weight bias in overweight/obese people. Eat Weight Disord, 18, 441-5. Access full text: http://www.ncbi.nlm.nih.gov/pubmed/24057679 Aim: In this brief report, an unanswered question in implicit weight bias research is addressed: Is weight bias stronger when obese and thin people are pictured engaging in stereotype consistent behaviors (e.g., obese-watching TV/eating junk food; thin-exercising/eating healthy) as opposed to the converse? Conclusion: Implicit weight bias was evident regardless of whether participants viewed stereotype consistent or inconsistent pictures. However, implicit bias was significantly stronger for stereotype consistent compared to stereotype inconsistent images. CARELS, R. A., YOUNG, K. M., WOTT, C. B., HARPER, J., GUMBLE, A., HOBBS, M. W. & CLAYTON, A. M. 2009. Internalized weight stigma and its ideological correlates among weight loss treatment seeking adults. Eat Weight Disord, 14, e92-7. Access full text: http://www.ncbi.nlm.nih.gov/pubmed/19934642 There are significant economic and psychological costs associated with the negative weightbased social stigma that exists in American society. This pervasive anti-fat bias has been strongly internalized among the overweight/obese. While the etiology of weight stigma is complex, research suggests that it is often greater among individuals who embrace certain etiological views of obesity or ideological views of the world. This investigation examined 1) the level of internalized weight stigma among overweight/obese treatment seeking adults, and 2) the association between internalized weight stigma and perceived weight controllability and ideological beliefs about the world ('just world beliefs', Protestant work ethic). Forty-six overweight or obese adults (BMI >or=27 kg/m2) participating in an 18- week behavioral weight loss program completed implicit (Implicit Associations Test) and explicit (Obese Person's Trait Survey) measures of weight stigma. Participants also completed two measures of ideological beliefs about the world ("Just World Beliefs", Protestant Ethic Scale) and one measure of beliefs about weight controllability (Beliefs about Obese Persons). Significant implicit and explicit weight bias was observed. Greater weight stigma was consistently associated with greater endorsement of just world beliefs, Protestant ethic beliefs and beliefs about weight controllability. Results suggest that the overweight/obese treatment seeking adults have internalized the negative weight-based social stigma that exists in American society. Internalized weight stigma may be greater among those holding specific etiological and ideological beliefs about weight and the world. Obesity Learning Centre Literature Update: Stigmatisation and obesity. February 2015 24 CARELS, R. A., BURMEISTER, J., OEHLHOF, M. W., HINMAN, N., LEROY, M., BANNON, E., KOBALL, A. & ASHRAFLOUN, L. 2013. Internalized weight bias: ratings of the self, normal weight, and obese individuals and psychological maladjustment. J Behav Med, 36, 86-94. Access full text: http://www.ncbi.nlm.nih.gov/pubmed/22322909 Current measures of internalized weight bias assess factors such as responsibility for weight status, mistreatment because of weight, etc. A potential complementary approach for assessing internalized weight bias is to examine the correspondence between individuals' ratings of obese people, normal weight people, and themselves on personality traits. This investigation examined the relationships among different measures of internalized weight bias, as well as the association between those measures and psychosocial maladjustment. Prior to the beginning of a weight loss intervention, 62 overweight/obese adults completed measures of explicit and internalized weight bias as well as body image, binge eating, and depression. Discrepancies between participants' ratings of obese people in general and ratings of themselves on both positive and negative traits predicted unique variance in measures of maladjustment above a traditional assessment of internalized weight bias. This novel approach to measuring internalized weight bias provides information above and beyond traditional measures of internalized weight bias and begins to provide insights into social comparison processes involved in weight bias. DURSO, L. E. & LATNER, J. D. 2008. Understanding self-directed stigma: development of the weight bias internalization scale. Obesity (Silver Spring), 16 Suppl 2, S80-6. Access full text: http://www.ncbi.nlm.nih.gov/pubmed/18978768 Aim: The present study developed the Weight Bias Internalization Scale (WBIS), an 11-item measure assessing internalized weight bias among the overweight and obese. Conclusion: Results indicate that the WBIS had high internal consistency (Cronbach's alpha = 0.90) and correlated significantly with antifat attitudes but was not a completely overlapping construct (r = 0.31). The scale showed strong partial correlations with self-esteem (r = -0.67), drive for thinness (r = 0.47), and body image concern (r = 0.75), controlling for BMI. Internalized weight bias was also significantly correlated with measures of mood and eating disturbance. Multiple regression analyses were conducted using WBIS scores, antifat attitudes, and BMI as predictor variables of body image, mood, self-esteem, and binge eating. WBIS scores were found to significantly predict scores on each of these measures. LEWIS, S., THOMAS, S. L., BLOOD, R. W., HYDE, J., CASTLE, D. J. & KOMESAROFF, P. A. 2010. Do health beliefs and behaviors differ according to severity of obesity? A qualitative study of Australian adults. Int J Environ Res Public Health, 7, 443-59. Access full text: http://www.mdpi.com/1660-4601/7/2/443 Public responses to obesity have focused on providing standardized messages and supports to all obese individuals, but there is limited understanding of the impact of these messages on obese adults. This descriptive qualitative study using in-depth interviews and a thematic method of analysis, compares the health beliefs and behaviors of 141 Australian adults with mild to moderate (BMI 30-39.9) and severe (BMI > or = 40) obesity. Mildly obese individuals felt little need to change their health behaviors or to lose weight for health reasons. Most believed they could "lose weight" if they needed to, distanced themselves from the word obesity, and stigmatized those "fatter" than themselves. Severely obese individuals felt an urgent need to change their health behaviors, but felt powerless to do so. They blamed themselves for their Obesity Learning Centre Literature Update: Stigmatisation and obesity. February 2015 25 weight, used stereotypical language to describe their health behaviors, and described being "at war" with their bodies. Further research, particularly about the role of stigma and stereotyping, is needed to fully understand the impact of obesity messaging on the health beliefs, behaviors, and wellbeing of obese and severely obese adults. LILLIS, J., LUOMA, J. B., LEVIN, M. E. & HAYES, S. C. 2010. Measuring weight self-stigma: the weight self-stigma questionnaire. Obesity (Silver Spring), 18, 971-6. Access full text: http://www.ncbi.nlm.nih.gov/pubmed/19834462 Stigma associated with being overweight or obese is widespread. Given that weight loss is difficult to achieve and maintain, researchers have been calling for interventions that reduce the impact of weight stigma on life functioning. Sound measures that are sensitive to change are needed to help guide and inform intervention studies. This study presents the weight selfstigma questionnaire (WSSQ). The WSSQ has 12 items and is designed for use only with populations of overweight or obese persons. Two samples of participants--one treatment seeking, one nontreatment seeking--were used for validation (N = 169). Results indicate that the WSSQ has good reliability and validity, and contains two distinct subscales-self-devaluation and fear of enacted stigma. The WSSQ could be useful for identifying individuals who may benefit from a stigma reduction intervention and may also help evaluate programs designed to reduce stigma. PUHL, R. M., MOSS-RACUSIN, C. A. & SCHWARTZ, M. B. 2007. Internalization of weight bias: Implications for binge eating and emotional well-being. Obesity (Silver Spring), 15, 19-23. Access full text: http://www.ncbi.nlm.nih.gov/pubmed/17228027 Aim: This study examined the relationship between internalization of negative weight-based stereotypes and indices of eating behaviors and emotional well-being in a sample of overweight and obese women. Conclusion: Participants who believed that weight-based stereotypes were true reported more frequent binge eating and refusal to diet in response to stigma experiences compared with those who reported stereotypes to be false. The degree to which participants believed stereotypes to be true or false was not related to types or amount of stigma experiences reported, self-esteem, depression, or attitudes toward obese persons. In addition, engaging in weight loss strategies as a response to bias was not predicted by stereotype beliefs or by actual stigma experiences, regardless of the amount or types of stigma reported. These findings suggest that obese individuals who internalize negative weight-based stereotypes may be particularly vulnerable to the negative impact of stigma on eating behaviors and also challenge the notion that stigma may motivate obese individuals to engage in efforts to lose weight. This study highlights a new area of research that warrants attention to better understand weight stigma and its potential consequences for health. SCHWARTZ, M. B., VARTANIAN, L. R., NOSEK, B. A. & BROWNELL, K. D. 2006. The influence of one's own body weight on implicit and explicit anti-fat bias. Obesity (Silver Spring), 14, 440-7. Access full text: http://www.ncbi.nlm.nih.gov/pubmed/16648615 Aim: This study examined the influence of one's own body weight on the strength of implicit and explicit anti-fat bias. Conclusion: All weight groups exhibited significant anti-fat bias, but there was an inverse relation between one's own weight and the level of observed bias. Thinner people were more Obesity Learning Centre Literature Update: Stigmatisation and obesity. February 2015 26 likely to automatically associate negative attributes (bad, lazy) with fat people, to prefer thin people to fat people, and to explicitly rate fat people as lazier and less motivated than thin people. However, when the lazy stereotype was contrasted with another negative attribute (anxious), obese and non-obese people exhibited equally strong implicit stereotyping. Finally, a substantial proportion of respondents indicated a willingness to endure aversive life events to avoid being obese. For example, 46% of the total sample indicated that they would rather give up 1 year of life than be obese, and 30% reported that they would rather be divorced than be obese. In each case, thinner people were more willing to sacrifice aspects of their health or life circumstances than were heavier people. Obesity stigmatization and public health planning MACLEAN, L., EDWARDS, N., GARRARD, M., SIMS-JONES, N., CLINTON, K. & ASHLEY, L. 2009. Obesity, stigma and public health planning. Health Promot Int, 24, 88-93. Access full text: http://heapro.oxfordjournals.org/content/24/1/88.abstract Given the rise in obesity rates in North America, concerns about obesity-related costs to the health care system are being stressed in both the popular media and the scientific literature. With such constant calls to action, care must be taken not to increase stigmatization of obese people, particularly of children. While there is much written about stigma and how it is exacerbated, there are few guidelines for public health managers and practitioners who are attempting to design and implement obesity prevention programs that minimize stigma. We examine stigmatization of obese people and the consequences of this social process, and discuss how stigma is manifest in health service provision. We give suggestions for designing non-stigmatizing obesity prevention public health programs. Implications for practice and policy are discussed. POMERANZ, J. L. 2008. A historical analysis of public health, the law, and stigmatized social groups: the need for both obesity and weight bias legislation. Obesity (Silver Spring), 16 Suppl 2, S93-103. Access full text: http://www.ncbi.nlm.nih.gov/pubmed/18978770 History teaches that discrimination against socially undesirable groups leads to societal and governmental neglect of the stigmatized group's health problem. By placing weight discrimination in a historical context, this article demonstrates that legislation specifically aimed at rectifying obesity is less likely while weight bias is socially acceptable. Beyond obesity legislation, public health professionals may consider advocating for legislation directly targeting discrimination based on weight. This article reviews the history of discrimination against distinct groups and provides statutory solutions for discrimination based on weight. In addition to revising current statutes and regulatory rules, a unique statute targeting weight bias in the employment context is considered. PUHL, R. M. & HEUER, C. A. 2010. Obesity stigma: important considerations for public health. Am J Public Health, 100, 1019-28. Access full text: http://www.ncbi.nlm.nih.gov/pubmed/20075322 Stigma and discrimination toward obese persons are pervasive and pose numerous consequences for their psychological and physical health. Despite decades of science Obesity Learning Centre Literature Update: Stigmatisation and obesity. February 2015 27 documenting weight stigma, its public health implications are widely ignored. Instead, obese persons are blamed for their weight, with common perceptions that weight stigmatization is justifiable and may motivate individuals to adopt healthier behaviors. We examine evidence to address these assumptions and discuss their public health implications. On the basis of current findings, we propose that weight stigma is not a beneficial public health tool for reducing obesity. Rather, stigmatization of obese individuals threatens health, generates health disparities, and interferes with effective obesity intervention efforts. These findings highlight weight stigma as both a social justice issue and a priority for public health. Further reading Please note that the articles in this section of the update require subscriptions to access. The Obesity Learning Centre and the UK Health Forum regret that we are unable to supply Obesity Learning Centre users with full text articles at the present time. ANDREYEVA, T., PUHL, R. M. & BROWNELL, K. D. 2008. Changes in Perceived Weight Discrimination Among Americans, 1995–1996 Through 2004–2006. Obesity, 16, 1129-1134. ANNIS, N. M., CASH, T. F. & HRABOSKY, J. I. 2004. Body image and psychosocial differences among stable average weight, currently overweight, and formerly overweight women: the role of stigmatizing experiences. Body Image, 1, 155-167. ANTIN, T. M. & PASCHALL, M. J. 2011. Weight perception, weight change intentions, and alcohol use among young adults. Body Image, 8, 149-56. ASHMORE, J. A., FRIEDMAN, K. E., REICHMANN, S. K. & MUSANTE, G. J. 2008. Weight-based stigmatization, psychological distress, & binge eating behavior among obese treatmentseeking adults. Eating Behaviors, 9, 203-209. ASTON, M., PRICE, S., KIRK, S. F. & PENNEY, T. 2012. More than meets the eye. 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The following open access databases were searched: PubMed: http://www.pubmed.com Cochrane Library: http://www.thecochranelibrary.com/ Google Scholar: http://scholar.google.co.uk/ PubMed & Cochrane Library MeSH search strategy "Stereotyping"[Mesh]) AND "Obesity"[Mesh] Limits English language Humans Publication dates: 2004 – 2014 Google Scholar search strategy Obesity and (“stereotyping” or “stereotype” or blame or bias or stigma or discrimination or bully) Search record Database Date of search PubMed 9 January 2015 Google Scholar 9 January 2015 Cochrane Library 9 January 2015 Details and comments No. records retrieved 215 259,000 results found. Scanned first 200 results and retrieved 82 relevant records. 82 15 Obesity Learning Centre Literature Update: Stigmatisation and obesity. February 2015 38