appearance out of concern for their health and well‐being, yet ultimately reinforce society’s stigmatizing weight messages [52]. Siblings are also a prominent source of weight‐based teasing [52]. However, peers are the leading source of weight‐based victimization in youth [12].
Weight‐based peer victimization comprises a variety of prejudicial or discriminatory behaviors targeting youth perceived to have excess weight, such as name‐calling, teasing or systematic bullying (verbally or physically, in‐person or online and through social media), social exclusion, and other forms of harassment (such as being the target of rumors [53]). According to a 2017 policy statement from the American Academy of Pediatrics, weight is among the most common reasons for teasing and bullying, as reported by children, teachers, and parents [45]. In an examination of 31,770 respondents in the 2016–2017 National Survey of Children’s Health, adolescents with overweight and obesity aged 10–17 years were significantly more likely than their lower weight peers to experience peer victimization, with odds ratios of 1.34 and 2.03 for overweight and obesity, respectively [54]. In another study of over 2700 teenage adolescents, weight‐based harassment was the most commonly reported type of peer victimization among adolescent girls (compared to other reasons for harassment, such as race or socioeconomic status) and the second most commonly reported among adolescent boys [55].
To provide a more in‐depth understanding of this issue, Puhl et al. [56] surveyed 1555 high school students about their perceptions of the types of peer victimization they witnessed. Students reported that weight was the primary reason students were teased or bullied at school, above sexual orientation, academic ability, race/ethnicity, physical disability, religion, and socioeconomic status. Over 84% of students had personally witnessed explicit weight‐based peer victimization (such as teasing), while 65–77% of students reported observations of more nuanced peer victimization (such as exclusion, avoidance, or spreading rumors targeting students with a higher weight). Half of the students reported that they had historically remained passive and did not advocate for their peers when they witnessed weight‐based teasing in the past. Further, students with weight‐biased attitudes (as measured by the Fat Phobia Scale) were significantly less likely to report helping their peers if they witnessed weight‐based peer victimization.
Experiences of peer victimization may contribute to other social difficulties for youth with a higher weight. In a study of over 31,000 adolescents aged 11–17 years, adolescents with overweight/obesity were more frequently reported by parents to be engaged in bullying behaviors (as both the bully and the victim) when compared to lower‐weight peers [54]. Adolescents with overweight had 34% greater odds of being a victim of bullying and 37% greater odds of being both a bully and a victim, but odds of being a bully perpetrator alone (without experiencing victimization) did not differ across weight groups. Additionally, adolescents with overweight/obesity had significantly greater odds of difficulty making friends, excessive arguing, and other behavioral conduct problems compared to lower‐weight peers.
Certain settings may present particular vulnerability for youth with obesity to be targeted. Cyberbullying in social media and other online spaces has become increasingly common in recent years [57] and is one of the most common forms of weight‐based victimization [12]. For example, in a recent investigation of over 10,000 children and adolescents (mean age = 12 years) from the Health Behavior in School‐Aged Children survey, BMI was significantly associated with greater frequency of both in‐person and cyberbullying [58]. Weight‐based victimization is also particularly prevalent in cafeterias and physical education (PE) settings [45]. For example, in a study of 361 adolescents enrolled in weight loss camps, 73% of participants reported that victimization occurred in PE class, in the gymnasium, during sports practice, or on the athletic field [12]. Vulnerability to mistreatment in PE settings may be further heightened by the high rates of weight‐based teasing from PE teachers and sports coaches reported by adolescents [12].
Rates of and responses to weight‐based peer victimization may differ by gender and race/ethnicity. As previously noted, girls report higher rates of weight‐based victimization by peers than do boys [48,49,55]. Compared to boys, girls also report that weight‐based victimization leads to more negative affect (e.g. feeling sad or worse about themselves; [49]). Relational peer victimization (e.g. social exclusion) may be more common than physical aggression in girls with obesity compared to boys [59], although gender differences in forms of weight‐based victimization are not consistently found [12]. With regards to race/ethnicity, some studies have not found differences in reports of weight‐based teasing, while others have found that weight‐based teasing specifically by peers is more frequently reported by White and Asian American youth compared to other groups [60–62]. White adolescent girls (but not boys) also report being more bothered by weight‐based teasing than do other racial/ethnic group members [60].
Impact of weight stigma on health
The anticipation, experience, and internalization of weight discrimination and stigmatization have profound effects on the mental and physical health of adults and youth with obesity. We summarize here the most recent evidence of and explanations for the robust associations between weight stigma and impaired health.
Discrimination
Weight‐based discrimination affects health through direct and indirect pathways. As with any other form of discrimination (e.g. due to race/ethnicity), disparities in education, employment, and wages hinder socioeconomic advancement. Poor health is consistently associated with socioeconomic status, in part due to the lack of resources and increased stress that accompany financial hardship [15,63]. In sum, weight‐based discrimination leads to losses of socioeconomic opportunities and advancement, which consequently increase stress and impair health [15].
The stress of anticipated and perceived weight discrimination affects those with a higher weight through direct pathways as well. The process of “identity threat” leads people with stigmatized identities (in this case, individuals with obesity) to be on heightened alert for the possibility of rejection or discrimination due to their identity [64]. This state of hypervigilance can activate the hypothalamus‐pituitary‐adrenal (HPA) axis, the body’s stress response system [64,65]. Release of stress hormones (such as cortisol) by the HPA axis can lead to changes in appetite and, if activated repeatedly over time, this can contribute to weight gain, chronic inflammation, and disease [65]. Already well‐established in the broader discrimination literature [66], recent studies have increasingly found support for identity threat processes and stress in relation to weight discrimination. In large‐scale, observational studies, perceived weight discrimination has been found to be associated with greater self‐reported stress, as well as biological markers of stress and inflammation such as cortisol and C‐reactive protein [67–69].
Laboratory‐based experimental studies that manipulate exposure to weight‐stigmatizing scenarios (through the threat of interpersonal discrimination, reading news stories about weight discrimination, and viewing stigmatizing media portrayals of obesity) have also found acute effects on cortisol, blood pressure, self‐reported stress, and caloric consumption among adults with overweight/obesity [70–73]. For example, a study of 110 undergraduate women randomly assigned participants to a shopping paradigm in which they were either told that they could not participate in shopping because the study was full, or because the clothes were not in their size (i.e. weight discrimination; [74]). Measures of salivary cortisol were taken before and 30 minutes after this manipulation. Results showed that participants who perceived themselves as overweight had higher sustained cortisol levels in the discrimination condition compared to those in the control condition (this effect was not observed among participants who did not perceive themselves as overweight). Although confined to the laboratory, findings from this and similar studies suggest that people may experience a biochemical stress response when facing real‐world instances of weight discrimination.
This stigma‐related stress response may explain many of the observed associations between weight discrimination and adverse health outcomes. Data from over 22,000 adults with overweight/obesity in the National Epidemiologic Survey of Alcohol and Related Conditions showed associations between perceived weight discrimination and increased prevalence of depression, anxiety, and