When will the stigma of obesity end?

The size of the overweight and obese population in China has exceeded 300 million people, and the increasing obesity stigma is likely to lead to weight discrimination, which will be detrimental to the construction of a community society. The study draws on the analytical perspective of body-involving theory to sort out the social roots of obesity stigma, individual internalization mechanisms, and negative effect factors. The spillover effect of obesity stigma can have a negative impact on individuals, groups and even society. The image of obese people constructed by others will cause the external normative effect of stigma, while the self-image perception will continuously internalize the negative effect of obesity stigma. Therefore, under the leadership of the value concept of human destiny community, it is necessary to improve the comprehensive literacy level of individuals and groups such as physical literacy, health literacy and physical literacy, especially it is necessary to pay attention to the health education of the key group of adolescents and children.

This article is from WeChat public number: China Youth Studies (ID: china-youth-study), author: Wang Junli, original title: “Research on the Obesity Stigma Phenomenon and Its Governance

When will the stigma of obesity end?

Between 1975 and 2016, the global overweight and obesity rate among adolescents and children aged 5 to 19 years increased more than threefold from 4% to 18% [1]. The latest national physical fitness monitoring results also show that the detection rate of obesity among school and university students in China continues to rise, and the overweight rates among adults and the elderly are 32.7% and 41.6%, respectively; overweight and obesity have become potential risk factors affecting the qualitative health of adolescents, adults, and elderly groups in China.

Under the deteriorating obesogenic environmental conditions, the epidemic of overweight and obesity and its negative effects on health will become a public health challenge in the future. At the same time, when the obesity epidemic becomes a widespread social phenomenon, the problem of weight discrimination caused by overweight and obesity deserves particular attention and focus.

From the perspective of the common good, whether it is the whole human race, the whole nation, or a family or an individual, all are interconnected and share the same fate. Even the small community we live in needs to have a sense of “community of human destiny”, individual exclusion or stigmatization is not good enough for itself, and is not conducive to overall harmony and common development.

At the same time, obesity stigma or weight discrimination is also a social and moral dilemma involving body ethics, which not only brings physical and mental harm to individuals but also is not conducive to the harmonious development of society. The problem of overweight and obesity from a philosophical perspective essentially belongs to the category of body phenomenology, because the body is not only a biological existence, but also a social, cultural, economic and other multidimensional existence. Thus, thinking about the phenomenology of the body will undoubtedly enhance people’s overall understanding of the existence of the body [2].

The topic of the body has received increasing attention from the academic community in recent years, and has even become a hot spot for research in academic fields such as philosophy of the body, sociology of the body, aesthetics of the body, and economics of the body. Given that the body is a concrete unity of body and soul, matter and spirit, existence and thought, initiative and passivity, reality and possibility, creature and creator, individual and class, and a field where self and other, subject and object are entangled, the body dimension needs to be confronted and the intersubjectivity of the body needs to be treated correctly.

It is worth noting that obese people are widely confronted with misinterpreted bodies, other-constructed bodies, discriminated and even stigmatized bodies, which makes it difficult to speak about their body rights. Therefore, in view of the increasing size of the population of overweight and obese people, it is necessary to confirm the root cause and influence of the body stigma of overweight and obese people, and to correctly understand, reasonably dispel and scientifically manage the value conflict in this body crisis, which will help to build the body-related ethics and behavior norms of our harmonious society.

I. Obesity stigmatization phenomenon and its influence

  1. Understanding of obesity stigma

Stigma (stigma) is a derogatory and insulting label of society for certain individuals or groups, which makes individuals or groups possess or be believed to possess certain derogatory attributes and traits, and these attributes or traits not only make the stigmatized person produce self-defeating psychology, but also lead to discrimination and unfair treatment by society [3].

Stigma research emerged in the United States in the 1960s and only began to attract the attention of researchers in China at the beginning of this century. A.J. Stunkard is considered to be one of the first medical professionals to explore obesity stigma at the individual and societal levels, and he made important contributions to the field of obesity stigma and laid the foundation and direction of obesity stigma research, such as cultural influences on weight bias, stigmatizing behaviors of health care professionals, weight discrimination in children, and weight internalization bias in obese individuals, among others [4].

Another prominent scholar, Richardson and his colleagues, also conducted a classic study on obesity stigma [5], in which they instructed 640 elementary school students aged 10 to 11 years to view six photographs of children and arrange them in order of who they liked best to be friends with. Four of the pictures depicted children with various disabilities, such as children in wheelchairs, children on crutches, amputated hands, and facial deformities; one picture depicted an overweight child, and the sixth picture depicted a child with no disabilities and a normal weight. The overweight child was ranked lowest in the six pictures and was rated as the least attractive one. In light of this, obese children may suffer many adverse psychological, social, and physical effects for reasons of weight bias or discrimination.

In the case of obesity stigma, the social devaluation and discrimination against overweight individuals may stem from an unfriendly reaction to a certain abnormal appearance or exhibit an inference of undesirable psychological traits that generate motivation to stay away from obese individuals [6]. Although research on the causes of obesity stigma has generated many interpretive theoretical hypotheses, including the cognitive, motivational, evolutionary functional, and systemic institutional theories, among others, there is still a need to reexamine the issue of obesity stigma and to shift the focus of research from the devaluation of individual identity to the phenomenon, mechanisms, and governance of the exclusion of individuals who meet certain criteria from various social interactions as scientific cognition continues to evolve.

  1. The ubiquitous phenomenon of obesity stigma

The internet, news, and videos of contemporary society are often filled with obesity-related topics, and overweight and obese adults and adolescents are 65% and 77% likely to be portrayed in a negative or even insulting light, respectively, and even more so, overweight and obese individuals may be portrayed as retarded and irresponsible for their bodies [7]. This, combined with discrimination by peers, parents, educators, and others against overweight and obese adolescent children, often leads to psychological, social, and physical discomfort for the individual adolescent. Not only do 28% of teachers believe that obesity is the worst thing that can happen to a person, but parents also provide less support for their overweight children [8].

Overweight obese adolescent children face similar difficulties socially and emotionally, and this problem appears earlier and becomes more pronounced the more severely obese the individual is. Obese children are now significantly less accepted than they were in the 1960s (H=130.53, p<0.001) and girls are less liked by obese children than boys (H=5.23, p<0.02), while the level of prejudice against obesity has increased [9]. In conclusion, obese adolescent children are often ignored by their peers and can even be excluded from peer networks.

For the adult population, obese individuals (with a body mass index of 35 or higher) are equally vulnerable to discrimination during interpersonal interactions, have lower levels of self-acceptance than normal weight adult individuals, and may themselves be affected by discriminatory evaluations of their weight or appearance. Obesity discrimination at work can take many forms, such as not being hired normally at work, being paid lower wages, being demoted, and not being promoted in their position. Obese candidates will be discriminated against to a greater extent in different workplaces, especially in physically demanding occupations.

Although there is only an unhealthy risk probability of overweight and obesity, employment discrimination based on weight has gradually developed into a widespread social problem. In view of the above situation, relevant departments should formulate and introduce policies on fair treatment of obese people to prevent overweight and obese people from becoming a hidden disadvantage in the construction of a harmonious society.

  1. The negative influence of obesity stigma phenomenon

Although the medical complications of obesity still need continuous professional attention, the psychological, physical and social effects caused by the stigma of obesity also need to be actively dealt with and dissipated. Stigmatization has become one of the triggers for frequent physical and psychological harm to obese individuals, who often struggle to overcome stigma. However, if obese individuals are frequently exposed to stigmatizing situational conditions, greater psychological distress, more attempts to cope, and even worse weight gain will follow.

Stigma, bullying, and discrimination against obese adolescent children can have serious adverse consequences, such as a range of potential negative effects on academic, employment, social, and other aspects of academic life growth. If obese individuals are ridiculed by their peers or become overly concerned about their personal body image, it may instead lead to lower sports participation among adolescent girls and sometimes to depression among the severely obese. The frequency of experiences of stigmatization among obese individuals is positively associated with depression, general psychiatric symptoms, and poor body image, and their own negative perceptions of weight discrimination are also closely related to the psychological harm they have suffered [10].

The internalization of obesity stigma can be understood as the accumulation of certain cognitive experiences of body image devaluation by obese individuals in the course of their constant interaction with the external world and the formation of a relatively stable cognitive structure in the mind in the form of perceptions. Although body weight is largely perceived as controllable, these stigmatizing experiences may lead to an increased risk of binge eating, reduced willingness to physical activity and dieting as a result of the internalization of obesity stigma [11]. Therefore, the general response of individuals to weight discrimination may be binge eating, a self-abusive response and behavior that will further lead to weight gain and increased risk of obesity.

Compared to normal weight individuals, obese individuals often have misinterpretations of their body size and exhibit preconceived anxious notions about weight and weight gain, even hoping to lose weight through frequent dieting behaviors. At the same time, these eating irregulars may have poorer social adjustment, to some extent related to their previous experience of obesity stigma.

If one draws on cyclical obesity prediction models constructed by theories from disciplines such as social psychology, health psychology and neuroendocrinology, one finds that obesity stigma tends to trigger a positive feedback loop of weight gain [12]. Conversely, if obesity stigma can be eliminated or reduced, better mental health benefits can be generated. Furthermore, for obese individuals with highly internalized weight stigma, conventional interventions may not be significantly effective and more innovative and direct approaches are needed to reduce the degree of stigma internalization.

Given that the preconceptions of obesity stigma are overly focused on appearance and not judged by ability, they may evolve into a variety of injustices. For example, socioeconomic status is related to body mass index (BMI) [13], and the negative correlation between wage earnings and BMI implies discriminatory effects of consumers or employers on obese individuals. If an obese individual is discriminated against in employment, an employer may refuse to hire an otherwise qualified candidate because of being overweight. In this way, not only will the obese be deprived of employment opportunities, but also may cause social division and antagonism, and ultimately jeopardize the harmony and stability of social development.

Second, the body image construction mechanism of obesity stigma analysis

  1. The body image of obese people constructed by others

The body is not only a dynamic aesthetic subject but also an aesthetic object, it is both a general tool for engaging in aesthetic activities and an object that can be sculpted and designed. With the advent of post-industrial society, the body has come to the forefront and become the object of need and subject of consumption, and even the object of consumer culture construction, and the “body image” is actively designed and consumed. Body image is considered as a multidimensional structure, which mainly includes perception, subjectivity and behavior [14].

Visibility always reveals our bodies and the dependency of our existence, always suggesting that we are concretized and secularized beings. Or rather, the body is just a being that is “placed” before its action, that is, the body imitates something or reproduces something [15]. The other’s view of the body was first seen in the medical field, such as the anatomical view of the body, which is essentially a view of the object body. When the body is viewed through the eyes of the other, external and objectified, it is seen as an object of knowledge that is independent of the observer and in the objective world [16]. And the body image in the eyes of the Other not only maps my body, but also constructs my body. The individual me’s initial perception of the body image may also come from the Other, like the body in the mirror, constantly shaping the body’s existence.

A wide variety of media, from television shows to books, newspapers, and the Internet, prejudicially portray images of overweight and obese bodies from the perspective of the Other. Even 4- to 6-year-olds have a tendency to have weight preferences, such as the belief that obese children are less likely to win competitions. While not rejecting obesity outright, children mostly show an orientation away from obese individuals in their choice of friendships; if forced to choose between roles, obese individuals are often rejected in most groups [17].

Thus, what others say and think about obesity not only determines the obese person’s own perception of body image, but even gradually internalizes a standard norm to be unknowingly shared.

  1. The obese person’s internalized self-image of the body

The body, freed from the haze of spiritual domination, has become a subjective reality of youth, health, beauty, and happiness, and is increasingly going beyond the internal ontological function of the body, even falling into a “narcissistic” body discipline and maintenance process [18]. Although the body can be widely valued for its form or appearance, it can also be used as a tool for interaction, exploration, and experience with the world.

The body has not only an aesthetic character but also an instrumental or functional character. Thus, body imagery is not limited to the perception of physical attractiveness, or the way the body “looks”; it also extends to the perception of how the body feels, moves, and functions, or what the body can do.

In fact, at least a quarter of normal-weight women are dissatisfied with their weight and body shape, and more than two-thirds of overweight and obese women are dissatisfied with their weight and body shape. Sixty-five percent and 95% of normal weight and overweight obese women, respectively, want to lose weight [19]. Although there were also differences in body image and body imagery functions among girls who participated in different types of sports, girls who did not participate in sports activities showed lower levels [20].

Certainly, girls in the adolescent population were significantly more dissatisfied with body image than boys. Although the entire adolescent population had higher levels of aesthetic value, behavioral investment, and satisfaction on the body function dimension, though girls had higher levels of aesthetic value and aesthetic behavioral investment, as well as lower levels of aesthetic satisfaction, functional value, functional behavioral investment, and functional satisfaction than boys [21].

If individuals exhibit relatively low body appearance ratings, they also exhibit higher weight anxiety [22], to the extent that the topic of obesity has been clearly normative in terms of self-depreciation of personal body image, and habits of thought of negative body image have a greater impact on self-esteem and eating disorder tendencies, which can be seen as a form of psychological inertia and deepen the understanding of body dissatisfaction in adolescents. If there are preconceived misconceptions about self-perceived obese individuals, the same can lead to lower salary requirements for individuals at work and they are more prone to discriminatory behaviors [23]. In conclusion, the body is the beginning of all good things, but a healthy and beautiful body begins with the accumulation of knowledge literacy and the process of translating that knowledge into action [24].

Third, the governance response to the phenomenon of obesity stigma

Obesity may be a symptom caused by a variety of complex causes, and obesity should not be stigmatized. Obesity stigma is not only a matter of individual rights, but also one of the main obstacles to prevent and control the obesity epidemic. Since 2015, various festivals on obesity have been held across the globe to promote health awareness and fight the obesity epidemic.

  1. Internalizing Perceptions and Enhancing Action Skills with Physical Literacy Education

Generally, stigma begins with the perception and marking of deviant normative transgressions and forms an overall impression of the transgressor based on this, creating a direct association with the transgressor through the attribution mark of responsibility, which in turn damages the integrity of the transgressor’s personality and identity [25].

The media nowadays have a direct impact on the perception of body image and play a normative role in body stigma. The identity of the obese is more than a simple individual psychological process; it reflects the relationship between the individual and society, and the individual and the collective. For example, there are significant gender differences in body image among college students in both China and the United States, with female students all having relatively low levels of self-body image satisfaction, but American female students have stronger predictive effects on physical activity volume in terms of body satisfaction in terms of appearance ratings, appearance attitudes, body mass attitudes, and overweight apprehension [26].

In general, normal weight yoga/meditation practitioners were more satisfied with their weight and form compared to individuals who never participated in yoga/meditation. However, 71.8% of male and female adolescents had body image distortion (BID), and 51.3% of individuals may underestimate their body image [27].

In addition, people’s fear of obesity is prone to stress and anxiety, and the resulting overeating may become a basic behavioral manifestation of the fear of becoming obese. Given all these factors, eliminating obesity stigma requires transforming the unhealthy body image perceptions that society, the collective, and individuals have developed, identifying overweight and obese individuals as members of the community, and strengthening individuals’ body literacy education, forming good body values, and paying attention to enhancing self-image corrective behaviors.

As body literacy education has been seen as an important tool to fight against the diseases of civilization in modern society, to ensure a better state of health and extensive participation in social life for each individual [28].

Essentially, physical literacy (physical literacy) refers to the motivation, confidence, physical ability, knowledge, and understanding of individuals to value and engage in physical activities throughout their lives. Its also seen as a generalized, inclusive, and universal value concept that encompasses the knowledge, skills, understanding, and values associated with purposeful engagement in physical and human activities over the life course, regardless of physical or mental limitations. The values of physical literacy education then are.

(1) Developing physical potential with the satisfaction of gaining experiences of progress and success.

(2) Establishing value judgments of physical participation.

(3) developing confidence to participate in a wide range of physical activities

(4) To gain knowledge and understanding of the nature and components of movement.

(5) To gain knowledge and understanding of the principles of holistic health and to develop a personal stance.

(6) recognizing the importance of taking responsibility for one’s well-being and deciding to fulfill one’s personal responsibilities [29].

Thus, physical literacy is essential for promoting overall health, well-being, and maximizing human potential, and individuals who are physically literate can confidently demonstrate and apply relevant knowledge and demonstrate proficiency in a range of physical engagements.

As life circumstances change, individuals are able to effectively modify physical behavior plans and use useful information to make independent, evidence-based decisions to improve the quality of life for themselves and their families. Whether in physical fitness, exercise programs, or recreational activities, physically literate individuals are able to innovatively change, encourage, and maintain physical behaviors, ultimately increasing the level of awareness and competence in weight management for both groups and individuals.

In summary, in order to reduce obesity stigma and protect obese individuals or groups from harmful effects, efforts are needed to identify and evaluate effective methods and tools for destigmatization and to implement health education promotion policies that prevent weight discrimination. In addition, reducing the further stigmatization of overweight and obese young people requires a unified voice and concerted action by educators, parents, schools, public health initiatives, anti-bullying actions, and policymakers working together to increase vigilance.

  1. Research on mechanisms for strengthening stigma governance

Humans have mechanisms of pathogenic immunity to disease, such as perceiving and responding to morphological abnormalities in others through vision, and such mechanisms appear to work equally well in obesity stigma [30]. Currently, there are at least four mechanisms of action regarding obesity stigma: (1) direct behavior change, (2) indirect effects of psychosocial stress, (3) indirect effects through changes in social relationships, and (4) indirect structural effects of discrimination.

In summary, the many factor mechanisms of obesity stigma may promote weight gain and ultimately lead to the spread of obesity at the population level. Of particular importance is that women and children appear to be particularly vulnerable to these mechanisms. Theoretical models based on animal (especially rodent) studies have provided strong evidence that the combined effects of stress and in utero malnutrition may lead to induced abnormal changes in weight development, and even that paternal stress can alter the epigenetic environment and be transmitted to offspring via sperm, thereby affecting the development of the fetal neuroendocrine system [31].

Future governance studies could also link obesity stigma to diet-cortisol, such as in laboratory-conducted, randomized experiments with controlled weight, measured eating behavior, and cortisol as outcomes, and test whether psychological stress modulates these relationships. Longitudinal studies are also needed to carefully map the positive feedback mechanisms of obesity stigma and to test the presence of threshold effects and implement intervention studies of weight stigma perceptions.

Through simulation studies with social network changes and peer influence strengths, it was found that increased positive peer influence significantly reduced the prevalence of overweight and increased negative peer influence elevated the prevalence of overweight. Of course the effect of peer influence may also vary depending on the population distribution of BMI, with stronger peer influence increasing the proportion of overweight population when group-level BMI increases. In conclusion, controlling for peer influence in the social network in which an individual lives may be a useful governance strategy, but further research needs to be explored [32].

Currently, although the impact of a single sport has a smaller impact on body image, exercise has advantages over other types of treatment because advocacy for exercise can benefit a wider audience (i.e., a scale effect). Moreover, other practical advantages of physical activity are even greater, such as low cost, almost negligible side effects, and still a widely accepted health behavior in society. Nonetheless, further research is now needed on the mechanisms and doses of exercise required for body image change.

In conclusion, more diverse interdisciplinary research may be needed in the future, first to scientifically understand the extent to which discriminatory attitudes are transformed into stigmatizing behaviors and the process mechanisms by which behaviors occur; second to better understand the psychological, social, and cultural roots of stigma, the methodological means of evaluating the consequences of stigma; and finally to dissipate negative societal attitudes and to take social action, legal and legislative, etc., to address the problem of obesity stigma Measures.

  1. Building a community society against stigma

Weight discrimination is harmful to health, human rights and social interests, and is unacceptable in modern society. A multidisciplinary international group of experts developed a joint consensus statement recommending the elimination of weight discrimination in a public article in Nature Medicine in March 2020 [33], emphasizing that academic institutions, professional organizations, the media, public health authorities, and governments should encourage education about weight discrimination in order to advance a new narrative about obesity that is consistent with modern scientific understanding. A panel of experts from The Obesity Society (The Obesity Society), drawing on a combination of scientific extrapolation, forensic identification, and pragmatism, argued that it may be more positive to consider obesity as a disease [34].

This could seek additional resources for obesity prevention, treatment, and research, could encourage more high-quality professional caregivers to view the treatment of obese patients as a profession worthy of effort and respect, and reduce the stigma and discrimination that health care professionals place on many obese individuals. Although not the subject of disenfranchised discrimination as in the case of AIDS and homosexuality, obese people inevitably suffer from social and institutional injustice. Existing laws offer extremely limited protection against obesity discrimination, so legislative efforts against obesity discrimination are necessary.

In the process of rapid transformation of contemporary Chinese society, the trend of pan-stigmatization, in which the phenomenon of stigma is increasing, the object of stigma is generalizing, the form of stigma is gradually diversifying, and the relationship of stigma is becoming more intertwined and complex, such as disease stigma, identity stigma, gender stigma, industry stigma, racial stigma, and geographical stigma, is very unfavorable to the construction of a harmonious society [35].

At the root of this, the knowledge segregation under the high division of labor in modern society makes individuals’ cognitive ability and decision-making ability of risk relatively weak, while the value conflict and informational tension in the stranger society also combine to intensify the transfer and spread of mistrust, which in turn promotes the growing phenomenon of pan-stigma [36].

Generally speaking those individuals who are stigmatized mostly belong to relatively vulnerable groups. Although the most direct consequence of stigmatizing others is to gain a sense of personal superiority, stigmatized individuals will develop many undesirable psychological and behavioral traits, and will suffer from persistent emotional anxiety, depression, and even antisocial tendencies. Thus, if the exclusion and deprivation of disadvantaged groups by powerful groups is legitimized, labeling identity stigma may cause segregation and alienation between groups, and somehow lead to social confrontation and conflict.

In addition, society’s subjective judgment on obesity stigma is easily attributed to the stigmatized person’s own internal reasons, which not only makes the stigmatized person form a false perception, but also fails to objectively find a solution to the problem. This may not help to dissolve social conflicts, and is even less conducive to building a harmonious socialist society with a community of human destiny. Therefore, a harmonious society needs to reduce prejudice and discrimination among groups, and form a good state of mutual understanding, mutual help and cooperation among various social groups to realize a well-off society that is shared by all.

IV. Conclusion

China’s overweight and obese population is rapidly increasing, and the phenomenon of obesity stigma generated by weight discrimination has developed. For overweight or obese people, the weight discrimination formed by obesity stigma not only affects the daily life and work of adults, but also is not conducive to the healthy growth of youth, and is not conducive to the construction of a harmonious society. It is necessary to improve the physical literacy, health literacy and civilization literacy of the residents to shape a good human and social environment to remove the stigma of obesity.

Continuously strengthen the research on the governance of obesity stigma, especially the youth group whose obesity population is growing rapidly. Because the youth not only relate to the happiness of countless families, but also will be related to the future high quality talent pool of the country. As General Secretary Xi emphasized, a strong youth makes a strong China, and a strong youth makes a strong China.

Therefore, in the future, we should not only focus on the effects of physical development, psychological health, academic development, and interpersonal relationships brought about by weight discrimination among overweight and obese adolescents, but also carry out in-depth and extensive theoretical and practical research at different levels, such as top-level system design, policy implementation, health education, and comprehensive literacy enhancement.

[Fundamental research project: This paper is a project funded by the Central Universities Basic Research Business Fund, “Theoretical and practical exploration of the intervention of overweight and obesity in adolescents” (Project No. 2017WB20), and a project funded by Jiangsu Student Physical Health Promotion Research Center, “Physical activity level and physical health risk of elementary school students in Tongshan District, Xuzhou City”. Research on the relationship between physical activity level and physical health risks of primary school students in Tongshan District, Xuzhou City” (Project No. 2019A001)]

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