Weight Bias,Stigmatization,and Bullying of Obese Youth

Abstract

Obese children suffer psychological, social, and health-related consequences of weight bias and discrimination. Weight-based stigmatization toward obese youth is unrelenting, pervasive, and cruel. This paper reviews the definitions of weight-related bias and victimization, including bullying, discusses the consequences of these acts, examines current anti-bullying programs, and suggests future directions. The author recommends that all overweight or obese children (especially in school or clinical settings) be assessed for weight-based victimization with appropriate interventions employed if discovered.

Introduction

Overweight and obese youth frequently face bias, stigmatization, prejudice, and bullying due to their excess weight. This abuse begins early in childhood and peaks during the school-age and adolescent years. Documentation of this abuse comes from peers, parents, and educators.^1–3 Weight bias is also likely experienced by youth from medical professionals and employers, as currently documented in obese adults.⁴

This paper defines terms related to bias, examines the nature and extent of weight bias in youth, and discusses weight bias sources and consequences. The concept of attribution is reviewed. An in-depth look at bullying, a specific weight victimization behavior, follows. The relationship of bullying and youth suicide is examined. Strategies and interventions to address weight bias in children and adolescents along with resources are considered.

Definitions

In general, many words are used interchangeably to refer to negative attitudes about individuals based on suppositions about a group to which they belong. To add clarity, definitions for concepts discussed in this paper are provided.⁵

Bias: the inclination to form unreasoned judgments.

Prejudice: preconceived judgment or opinion that is a possible outcome of bias.

Stigma: the social sign or label/stereotype carried by the individual who is the victim of prejudice; this stereotype is likened to a devalued social identity that increases vulnerability to loss of status, unfair treatment, and discrimination.⁶

Weight stigma/victimization: negative weight-related attitudes and beliefs that are manifested by stereotypes, bias, rejection, and prejudice toward youth because they are overweight or obese.²

Bullying: aggressive, intentional act or behavior that is carried out by a group or individual repeatedly and over time; an imbalance of power exists between the bully and the victim who cannot easily defend himself.⁷ Bullying requires a perpetrator (bully) and victim. Often, bystanders are part of the bully/victim experience resulting in a bully/victim/bystander triad. Those who bully are frequently victims of bullying themselves and some victims also bully; research literature differentiates between bullies, victims, bully/victims, and bystanders.

Nature/Extent of Weight Bias

Obesity in youth is a national public health priority. In the United States, 17% of youth aged between 2 and 19 years are obese.⁸ In some low-income and minority communities, this percentage is higher.⁹ Overweight body mass index [BMI] for age >85th ≤95th percentile) and obese (BMI for age >95th percentile) youth face widespread weight-based stigmatization;² as obesity prevalence rates have increased among youth, so has weight-based stigmatization and prejudice.¹⁰

Overweight and obese adolescents are more likely to be victims of peer victimization (bullying and teasing) than their average-weight peers.^1,11 Adolescents observe and experience weight-based teasing to be the most common form of teasing at school.¹² Vulnerability to victimization corresponds to increases in BMI in adolescence, with the heaviest teens at highest risk for stigmatization.^13,14 The likelihood of additional victimization increases with each year of age, once an obese teen becomes the target of weight-based victimization.¹⁵

Researchers have studied weight-based stigmatization toward overweight children for more than 40 years.^10,16,17 In a classic study by Richardson et al. in 1961, researchers showed 640 10–11 year olds six pictures of children; four pictures depicted children with disabilities, one picture showed a normal-weight child (no disabilities), and one an overweight child (no disabilities). The children ranked the pictures in order of whom they would most prefer to have as friends. The overweight child ranked last and was rated as the least likeable.¹⁶ Latner and Stunkard replicated this study in 2003, with the overweight child again ranked last in order of preference as a friend; an additional finding showed that the distance between the average ranking of the highest and lowest pictures increased by 40% since the 1961 study.¹⁰

A recent study of 1,555 adolescents examined perceptions of weight-based victimization toward obese peers at school. The students surveyed reported witnessing obese peers being made fun of (92%), called names (91%), teased meanly (88%), ignored or avoided (76%), excluded from activities (67%), verbally threatened (57%), and physically harassed (54%).¹² The study found that while the majority of students reported a willingness to help their overweight peers when a target of teasing, approximately half of the students remained passive bystanders.

Specific prevalence rates of weight bias are difficult to determine, as research is not consistent in examining bias attitudes and stigma encounters with consistent assessment methods. Additionally, there is potential bias by the examiner; teasing may be considered “minor” and ignored during assessment questions; if asked “are you being bullied?” and a negative response is given, does this mean that there are no other forms of weight bias being experienced? Determining the prevalence of weight bias in youth is complex, and future research needs to account for potential differences in perceived weight stigma across variables such as gender, weight, age, and ethnicity.

Attribution

Attribution of the causality of obesity is an important variable in the formation of attitudes toward the obese.¹⁸ For example, 168 female adolescents evaluated an overweight peer more positively when that peer's excess weight was attributed to a thyroid condition as compared to a peer where an external cause was not provided. The peers without an external cause for their obesity were described by those studied as having poor self-discipline and being self-indulgent.¹⁹ Similar findings are documented in preschool children (participants who felt that weight was within personal control expressed more negative attitudes toward obese children)²⁰ and elementary school children (less likely to blame an obese peer if they felt the obese child has little responsibility for his obesity).^21–23 Attributions about causes of obesity may affect attitudes among overweight and obese children themselves. Obesity stereotypes emphasize that body weight is under personal control; it is possible that internalization of weight stigma by obese children may influence their attributions about the causality of their own obesity, which may in turn have negative implications for their emotional well-being.²

Sources of Weight Bias

Obese youth are vulnerable to bias and stigma from multiple sources. The current literature cites weight bias toward children and adolescents primarily in the area of peers, parents, and educators.

Children as young as 3 years old have been shown to have negative attitudes toward obese peers.²⁴ These children identified their overweight peers as “sloppy, stupid, ugly and mean” and overwhelmingly preferred the thin playmate compared to the overweight playmate picture. Elementary school children show a similar bias using similar adjectives to describe their overweight peers.^22,25,26 Studies in adolescents are consistent with this trend.²⁷ Negative attitudes that began in early childhood often persist into adolescence and may become worse as children get older.²⁸

Teachers are invested in the welfare and education of their students but are not immune to societal attitudes that stigmatize obese children; educators may unintentionally (or not) perpetuate bias toward overweight students. This bias can take the form of lower expectations of overweight students compared to normal-weight students.²⁹ Several recent studies highlighted weight bias in physical education classes and negative weight-related beliefs about overweight children and activity.^30,31

The home environment, traditionally a safe haven for children, also can be a source of weight bias and teasing. Studies indicate that 23–58% of obese youths report weight-based teasing from parents.^32–34 Parental weight-based teasing predicts hurtful weight-related teasing later in young adulthood.³⁵ An authoritarian parenting style and a belief of personal responsibility for weight may contribute to anti-fat attitudes by parents.³⁶

In adults, weight bias is documented in the areas of employment,³⁷ healthcare professionals³⁸ (physicians,³⁹ nurses,⁴⁰ medical students,⁴¹ fitness professionals,⁴² and dietitians⁴³), healthcare utilization,⁴⁴ education,⁴⁵ interpersonal relationships,⁴⁶ advertising,⁴⁷ and the entertainment and news media.³⁷ It is likely that weight stigmatization of youth by these groups exists as it does in adults. Future research is needed to determine the existence and extent of discrimination by these and other groups toward obese youth. Table 1 lists signs of possible weight-related victimization in youth.

Table 1.

Signs of Potential Weight-Based Victimization

• Increased absenteeism from school

• Torn/damaged possessions (clothing, book bags)

• Withdrawal

• Avoidance of social situations previously attended without hesitation

• Anxiety

• Sleeplessness

• Change in eating habits

Why is Weight Bias Tolerated?

Weight bias is tolerated because of beliefs that stigma and shame will motivate people to diet and lose weight—that the reason the obese fail to lose weight is poor self-discipline or lack of willpower. Our culture sanctions the overt expression of weight bias in a way not openly tolerated in other forms of discrimination (racial, gender, and religious). Only one state (Michigan) and three cities (Washington, DC, San Francisco, CA, and Santa Cruz, CA) have laws/codes that prohibit discrimination against overweight people.⁴⁸ Our society continues to blame the victim rather than consider or address conditions that may contribute to obesity.⁴⁹ Finally, our society allows the media to portray obese individuals in a biased and negative way. Until reason and compassion overcome bias and stigma, the tragedies related to the consequences of weight bias and bullying will continue. As healthcare professionals, it is our responsibility to assess, intervene, and act as role models for tolerance of obese youth.

Bullying: Embodiment of Weight-Related Victimization

Bullying is defined as an aggressive, intentional act or behavior that is carried out by a group or individual. The aggression is repetitive and against a victim who cannot easily defend him/herself.⁷ Bullying is abuse based on an imbalance of power between the perpetrator and the victim. The act of bullying is intentional harassment to cause fear or harm; there is no provocation from the victim for the act to occur.

Bullying is commonly categorized as verbal, physical, relational, and cyber.⁵⁰ Verbal bullying includes teasing, taunting, threatening—direct or face-to-face types of aggression. Physical bullying includes hitting, kicking, punching, taking/damaging property (backpack, etc.), spitting, or combative acts of violence. Relational (social) bullying is intentional damage to a peer relationship with the intent to damage self-esteem or social status. It takes the form of gossip, rumors, and social exclusion. Cyber bullying is aggression that occurs through technology with the purpose of using electronic medium to threaten or harm others.⁵¹ E-mail, chat rooms, cell phones, instant messaging, pagers, text messaging, posting embarrassing pictures on Web sites, and inappropriate use of YouTube are a few examples of abuse using cyber devices.

The known prevalence of bullying victimization in all preteens and adolescents ranges from 20–30% (www.stopbullying.gov/what-is-bullying/definition/index/html). Griffiths et al. (2006) studied more than 7,000 6–7 year olds; they found that 36% of obese boys were victims of physical bullying and 18% victims of relational bullying; 34% of obese girls were overt victims and 17% relational victims.¹⁴ Janssen et al. (2004) found that the prevalence of victims increased with increasing BMI category in 11–12-year-old boys, 13–14-year-old girls, and 15–16-year-old girls.¹³ The overall prevalence of cyberbullying is reported to range from 29% to 48% of middle and high school students.^52,53 The incidence of cyberbullying specifically related to obesity is not clear but should be included in assessment of at-risk children and adolescents.

Consequences of Weight Victimization for Youths

Weight-based victimization places obese and overweight youth at risk for negative psychosocial, relational, academic, and physical outcomes. Consequences of weight stigmatization affect feelings of self-worth and relationships with peers, family, employers (teens), and society.

Youth who are teased and bullied regarding their weight are vulnerable to the psychosocial consequences of depression, lower self-esteem, anxiety, and poor body image.^54,55 Of particular concern, research where investigators control for variables such as BMI suggests that negative psychological consequences are associated with weight stigmatization rather than excess body weight.^32,54

Relational consequences of weight bias include social isolation and rejection by peers by not being nominated to relationships, teams, groups, and so on within their school environment.⁵⁶ Friendships and dating relationships of adolescents are negatively affected by weight bias. Overweight adolescents are less likely to have ever dated or are more dissatisfied with their dating status than their average-weight peers.⁵⁷ In a study of 9,943 adolescents by Falkner, adolescents report that obese students were less likely to spend time with friends than thinner peers.⁵⁸

Weight-based stigmatization may contribute to poor academic performance. In two studies, obese youth had increased absenteeism and poorer school performance when compared to non-overweight peers.^59,60 A study by Puhl and Luedicke (2012) reports that the likelihood of a student skipping school because of weight-related teasing increases by approximately 5% for each weight-based teasing incident.⁶¹ The percentage of students who reported these teasing incidents to adults at the school was 23%; however, with each successive weight-based teasing incident, the likelihood of the student reporting to an adult increased by 4%, indicating the potential importance of a supportive and available school staff.

Physical consequences of weight-related victimization include disordered eating practices, decreased engagement in physical activity, and stress-related cardiovascular risks.⁶² Weight-based teasing is associated with eating disturbances. Overweight youth who experience frequent weight-related victimization engage in unhealthy weight-control and binge-eating behaviors more often than overweight youth not teased about their weight.³³ Haines et al. (2006) studied 2,516 teens, finding that 23% of females and 21% of males were victims of weight-based teasing.⁶³ After other variables were controlled for, the variable of being teased predicted binge eating at a 5-year follow-up.

Weight-based victimization may negatively affect physical activity levels in overweight youths. In a study of 576 middle school students, weight criticism during physical activities was related to negative attitudes toward sports and lower levels of physical activity.⁶⁴ Negative comments by teachers toward overweight students' athletic abilities may lead to avoidance of physical education classes.⁶⁵

Weight stigma may increase vulnerability to chronic stress and its negative effect on health.² Research suggests that stress induced by weight victimization and increased body mass may increase risks for adverse stress reactions (such as hypertension) in youth and that psychological stress predicts poor health outcomes.^62,66 Future research to determine how weight stigma induces psychological and physiological stress in youth and how this stress is related to indices of health and body weight is needed.

Bullying and Suicide

Suicide is the third leading cause of adolescent mortality in the United States.⁶⁷ In a 2009 surveillance of youth risk behavior, 17% of adolescent girls considered suicide, 13% had a suicide plan, and 8% attempted suicide; the incidence for adolescent boys was 10%, 8%, and 4.6% respectively.⁶⁸ Three studies of obese youth have found an increased risk of suicidal behaviors (ideation and attempts);^58,69,70 bullying and teasing were not assessed in these studies.

Two reviews are discussed here that show a strong correlation between bullying and risk of suicide; obesity was not specifically controlled for in these studies. These reviews are followed by a study by Eisenberg et al. (2003) who studied the association of weight-based teasing and emotional well-being (including suicide) among adolescents; a positive correlation was found.⁵⁴

Kim and Leventhal reviewed 37 studies that examined the association between bullying experiences and suicide in children and adolescents.⁷¹ Most studies in this review reported positive associations between bullying and suicidal risks; a higher suicidal risk was seen in females and youth with a higher frequency of bullying events. The reviewers note that several of the studies did not control effectively for a wide range of risk factors and none controlled for obesity. Kim and Leventhal encourage future studies to control for the effects of well-established suicidal risk factors. However, they conclude that the literature reviewed suggests bullying is a serious problem for youth that interferes with normal development and places youth at unnecessary and additional risk for suicidal thoughts and actions.

Cooper et al. (2012) also reviewed literature that studied an association between bullying and suicide.⁷² Kaminski and Fang conducted a secondary analysis of pooled data of three large adolescent surveys representing participants aged 11–21 years old.⁷³ The study controlled for gender, race/ethnicity, age, and depressive symptoms, which are important risk factors for adolescent suicide. Their results demonstrated significant increases in both suicidal ideation and maladaptive behaviors in bullying victims; females were at greater risk for suicidal ideation. A strong association also was found between bullying and adolescent suicide in international and U.S. studies focusing on the effects of bullying on the victim.^73–77 Hinduja and Patchin (2010) studied 1963 6th–8th grade preteens to determine if traditional bullying and cyberbullying were correlated with suicidal ideation and attempts.⁵² The researchers demonstrated that being a victim or perpetrator of both forms of bullying was associated with increased suicidal ideation and attempts; victims of bullying had a stronger association. The study also noted that cyberbulling victims were twice as likely to commit suicide. Rivers and Noret (2010) studied the effect of various bullying roles (bully, victim, bystander, combinations of all) and their correlation to suicidal ideation.⁷⁸ Adolescents with the greatest risk for suicidal ideation were those who had been a combination of bully, victim, and bystander followed in risk by the bully/victim. Bystanders had a slightly increased risk of suicidal ideation. Cooper et al.'s analysis of the reviewed literature found that the experience of bullying in youth is strongly correlated with suicidal behavior in adolescents with the possibility that bullying is a direct cause.⁷²

Most troublesome is research that suggests that obese youth who experience weight-based teasing (verbal bullying) are two to three times more likely to engage in suicidal thoughts and behaviors than overweight peers who are not victimized.⁵⁴ Eisenberg et al. studied middle and high school students assessing for weight-based teasing and emotional well-being. In a group of 4,746 students, they found 30% of adolescent girls teased by peers and 28.7% teased by family members (24.7% and 16.1% of adolescent boys respectively). Teasing about body weight was consistently associated with low body satisfaction, low self-esteem, high depressive symptoms, and suicidal ideation and attempts, even after controlling for actual body weight. These associations held across racial, ethnic, and weight groups. More than half of the adolescent girls teased (by either peers or family) reported suicidal ideation, and one quarter attempted suicide. The adolescent boys, who reported being teased by family, were three times more likely to have attempted suicide. This study demonstrates the importance of choice of words when assessing for weight-based victimization, using a spectrum of weight-based victimization terms (teasing vs. bullying).

Strategies to Address Bullying

The goals of anti-bullying programs are to prevent new victimization and to intervene in environments where bullying occurs. Program goals and interventions often overlap and build on each other. Some programs use very specific and focused curriculum; others are broader with a system focus.

In preventative programs, preventative interventions are often presented by trained personnel in educational sessions to teachers. Using a direct method, facts are presented about types, prevalence, and consequences of bullying; teachers subsequently conduct discussions with their classes to raise awareness of the problem and foster a commitment to reducing bullying behavior. Program components are aimed at developing empathy in students and providing counseling on appropriate anger management.⁷⁹

Using an indirect methodology to teach bullying prevention, educators train teachers to become more effective classroom managers. Basic skills for effective classroom management include modeling a caring attitude toward students; communicating clear indications of student expectations related to school, work, and social relations; and conducting sensitive interventions to address behavioral problems.⁸⁰

When choosing an intervention model where bullying exists, programs range from focused to community programs. A focused intervention model using traditional methodology emphasizes “zero tolerance” as a core principle—a model where the bully is disciplined (e.g. expelled) for behavior that violates an institution's (school) rules. While this method has the advantage of removing the bully from a particular situation, the act of removal of the instigator may not decrease other episodes of bullying within the environment.⁸¹

Broader-focused community-based programs emphasize a more comprehensive approach; these programs are most commonly implemented in school systems. Community programs emphasize a positive school climate where administrators, teachers, and school staff all receive training to establish a common set of behavioral expectations across all classrooms and school activities. Two programs using this approach are discussed here.

Dr. Daniel Olweus, a clinical psychologist from Norway, pioneered research on bully/victim relationships. Dr. Olweus began studying bulling in the 1980s and wrote his classic text about school bullying in 1993.⁷ From his ongoing research, Olweus developed the community-based approach to bullying (Olweus Bullying Prevention Program [OBPP] www.violencepreventionworks.org), which has been used worldwide for more than 35 years. (See Table 4 for website.) The OBPP program emphasizes a whole school approach with the goal of prevention or reduction of bullying throughout a school system. Education and interventions occur at the school, classroom, and individual levels; parents and community members are also involved. The program is implemented by school administrators, teachers, and staff; goals include improvement of peer relations and creation of a safer and more positive school environment. Schroeder et al. (2011) studied the effect of implementation of the OBPP on bullying over a 2-year period on more than 2,400 teachers and 56,137 students across Pennsylvania schools.⁸² After 2 years of implementation, there were reductions in student self-reports of bullying, and improvements in student perceptions of adults' responsiveness and students' attitudes about bullying.

Another model (School-wide Positive Behavioral Interventions and Supports [SWPBIS] www.pbis.org) uses the community-based philosophy through the methodology of positive-oriented universal behavioral prevention of bullying. (See Table 4 for website.) Waasdorp et al. (2012) assessed the impact of SWPBIS on school climate, bullying, and peer rejection during early adolescence.⁸³ More than 12,000 children were followed longitudinally across four school years. Results indicated a lower rate of teacher-reported bullying and peer rejection in schools that implemented SWPBIS compared to schools that did not implement the program. Results also suggested that the positive effects of SWPBIS on peer rejection were strongest in children exposed to the program at a younger age.

While these two programs and similar ones have encouraging results, the ideal program with universal impact on bullying remains elusive. Rigby and Slee (2008) reviewed more than 25 programs and concluded that although the effectiveness of anti-bullying programs is not guaranteed, their positive results justify the application of these interventions.⁷⁹ The reviewers concluded that multidimensional approaches are likely to be more effective, combining both preventive and interventive methods in the context of a whole-school approach. A range of factors may affect an anti-bullying program's effectiveness, including the readiness of the school as a whole to accept and thoroughly implement all aspects of the program. Further research on interventions that can enhance the success of anti-bullying programs is needed.

The role of the bystander (who witnesses the bully/victim dyad) is under renewed focus as a way to reduce the incidence of bullying by creating an emotionally healthy environment. Not intervening in a bullying situation assumes agreement to the victimization.⁸⁴ Bystanders are often sympathetic and want to help but are afraid and not sure what to do. Empowering the youth bystander is about bridging the gap between what children believe is right and what they actually do. Interventions to empower bystanders to intervene positively in supporting the victim include raising awareness, educating that intervention makes a difference, and providing a range of safe responses in bullying situations. Children often are confused between “tattling or snitching” and “tell an adult about bullying.” It is helpful for parents, teachers, and administrators to have open discussions about the philosophy of bullying management; consistent commitment to the anti-bullying plan is key.^84–86

Recommendations

Weight-related bias and stigma assumes many names: teasing, name-calling, passing rumors, tripping, bullying, harassment, and victimization are examples. These words evoke different levels of concern in society ranging from “rite of passage” and harmless to pathologic. The first hurdle when having the conversation about weight-related stigma is to agree that all forms of weight-based bias and stigma are not acceptable in any circumstance. Weight-based bias and stigma words and actions are tightly interwoven within our society and daily lives. Vigilance in self-examination is ongoing. Stereotypes run deep in our beings and all members of society face the task of continuously reframing our views of youth challenged by obesity.

Given what we know about the consequences of weight-based stigmatization, including risk of suicide, it is important for healthcare professionals to assess all obese youth for weight-related victimization—verbal, physical, relational, and cyber abuse. Areas of assessment include peer relationships, body image, eating behavior, self-esteem, depression, and anxiety (see Table 2). During assessment, healthcare professionals are mindful of potential biases and preconceived perceptions that impact their professional approach. Ongoing professional development that includes weight-bias literature in youth focuses the clinician on the latest research; this enables the clinician to provide meaningful counseling and intervention strategies. Many obese youth are seen episodically (emergency room, outpatient surgery, “Quick Care” clinics) where the focus of the visit(s) is on a particular problem rather than an overall health assessment. Strategies to address possible weight-based victimization are listed in Table 3. The challenges of short visits are numerous, but the opportunity to assess for weight-related bias and intervene appropriately may be lifesaving. As with other forms of child abuse, clinicians have an ethical and moral responsibility to “ask the questions.”

Table 2.

Weight-Based Victimization Assessment of Obese Youth: Areas to Assess and Document

• “Are you safe?”

• Peer relationships

• Bullying, teasing episodes; ask specific questions from “minor” to “major” events

• Academics

• School attendance patterns

• Body image

• Eating patterns

• Self-esteem

• Depression

• Anxiety

• Physical health assessment

Table 3.

Strategies for Addressing Weight-Based Victimization

Healthcare Provider	Teachers/School Administrators	Parents
• Let victims know you want to help • Listen to their story • Ensure confidentiality • Keep records of victimization and supporting documentation • Identify youth with increased or prolonged absenteeism • Work with school administrators to coordinate programs within the school system and community	• Create an environment intolerant of peer victimization • Research programs/interventions to implement school system wide • Conduct workshops on risk factors, warning signs, and consequences of bullying • Identify students with increased or prolonged absenteeism • Solicit community support	• Listen to their children and have conversations around bias, stigma, and types of bullying • Encourage strategies to empower children to become empathetic bystanders • Provide anticipatory guidance of potential bullying situations • Work with schools and communities to promote an environment intolerant of peer victimization

The media impacts society's view of obesity: values, attribution, and descriptions. The media's portrayal profoundly shapes the public's understanding and attitudes toward the obese and related areas. The Rudd Center for Food Policy and Obesity at Yale University (Rudd Center) along with The Obesity Society (TOS) believe that journalists have an obligation to be fair, balanced, and accurate in their reporting related to the obese and obesity. Portrayals are often negative and disparaging; reports about causes and solutions to obesity often reinforce stereotypes rather than offering balanced arguments. As a result, the Rudd Center and TOS developed guidelines for the portrayal of obese persons in the media (http://yaleruddcenter.org/resources/upload/docs/what/bias/media/MediaGuidelines_PortrayalObese.pdf.). These guidelines address respect for diversity, avoidance of stereotypes, appropriate language/terminology to describe body weight, balanced and accurate coverage of obesity, and appropriate use of pictures/images of obese persons. Images meeting these guidelines are available on the Rudd Center's website (www.yaleruddcenter.org). These guidelines are appropriate also for professional writing and presentations by clinicians. Images of obese youth used appropriately (or inappropriately) during presentations contribute to the message of the speaker. Raising awareness and role modeling is a constant opportunity in personal, professional, and community venues. See Table 4 for websites.

Resources

Resources to learn more about weight-based bias/stigma and bullying are readily available in professional research literature, books, and Web sites. Publications by Olweus reflect the history of bullying research. Yale's Rudd Center for Food Policy and Obesity Web site presents the Center's ongoing research efforts in weight bias, including abstracts and full articles of the Center's published research. The Centers for Disease Control and Prevention (CDC) present data, interventions, and resources on a variety of related topics, including childhood obesity, bullying, bias, and consequences of bullying maltreatment (www.cdc.gov). Bullying information and strategies are available for parents, educators, clinicians, and lay public at www.stopbullying.gov. Additional resources are listed on Table 4.

Table 4.

Resources: A Representative List ^**

Books:

• Bullying at School: Understanding Children's Worlds. Dan Olweus; Blackwell.

• Brownell KD, Puhl RM, Schwartz MB, Rudd L (eds). Weight Bias: Nature, Consequences, and Remedies. New York: Guilford Press; 2005:68–79.

• Davis S. Empowering Bystanders in Bullying Prevention. Champaign, IL: Research Press, 2007.

• Rigby K. Children and Bullying: How Parents and Educators Can Reduce Bullying at School. Malden, MA: John Wiley, 2012.

Websites:

• Weight bias/discrimination research/Public Policy www.yaleruddcenter.org

• Operation Safe Surf (Parents, educators, youth)www.attorneygeneral.gov/kidsparents.aspx?id=2323

• Cyber-bullying: What Parents Should Know www.aboutourkids.org/articles/cyberbullying_what)parents_should_know

• www.stopbullying.gov

• www.bullying.org

• Home of Olweus Bullying Prevention Program www.violencepreventionworks.org/public/index.page

• School-wide Positive Behavioral Interventions and Supports [SWPBIS] www.pbis.org

This list is meant to be representative of available resources and not intended as an exhaustive list.

Conclusion

Obese children suffer psychological, social, and health-related consequences of weight bias and discrimination. Weight-based stigmatization toward obese youth is unrelenting, pervasive, and cruel. Any form of bullying is as genuine a form of child abuse as any other. One could argue more so, as society is intolerant of other forms of child abuse but often stands by when youth (obese or not) are bullied.

Further research on obesity bias is needed to understand how attributions about the causality of obesity are formed in young children, the consequences of weight-bias toward youth, and how weight stigma impacts on children's physical health. In the area of bullying and related actions, continuing research includes a further understanding of attributes of bullies/victims/bystanders, consequences of bullying behavior on victims, and development/refinement of effective anti-bullying interventions and programs. Refinement of anti-bullying programs and suicide prevention efforts should develop in concert with the hope of reducing/eliminating suicidal ideation and attempts.

Tolerance of any behavior that is cruel and discriminatory, especially toward children, erodes society. Obese youth face challenges on many levels. As healthcare providers, it is our professional and moral obligation to examine continuously our own weight-related biases and prejudices. Given our society, it is unlikely that any of us are immune to these beliefs. Being honest with ourselves while challenging old assumptions of obesity will allow us to become more effective obesity clinicians. It is unlikely that any obese child has not experienced some form of obesity-related bias and stigma. No matter how “minor” the tease or how “major” the bullying, all forms of weight-related victimization carry the risk of psychosocial and physical consequences for our youth. Any overweight youth in our clinical practice should be routinely assessed for weight-based victimization with interventions implemented as appropriate. The most important intervention for the obese youth may be simply sharing the victimization experience with an empathetic adult who validates the inappropriateness of the behavior.

Footnotes

Acknowledgments

The author acknowledges Lizabeth Wallace and Carrie Stephens (Children's Hospital of Illinois, Order of St. Francis Medical Center, Peoria, Illinois) for their assistance and support in the preparation of this manuscript.

Disclosure Statement

No competing financial interests exist.

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