write about 3-4 main findings from the article assigned for this week . Be sure to also develop a discussion question about the article

How and why weight stigma drives the obesity 'epidemic' and harms health

A. Janet Tomiyama1*, Deborah Carr2 , Ellen M. Granberg3 , Brenda Major4 , Eric Robinson5 , Angelina R. Sutin6 and Alexandra Brewis

Background In a classic study performed in the late 1950s, 10- and 11-year-olds were shown six images of children and asked to rank them in the order of which child they 'liked best'. The six images included a 'normal' weight child, an 'obese' child, a child in a , one with crutches and a leg brace, one with a missing hand, and another with a facial disfigurement. Across six samples of varying social, economic, and racial/ethnic back- grounds from across the United States, the child with obesity was ranked last [1]. In the decades since, body weight stigma has spread and deepened globally [2, 3]. We define weight stigma as the social rejection and devaluation that accrues to those who do not comply with prevailing social norms of adequate body weight and shape. This stigma is pervasive [4-6]; for example, in the United States, people with greater body mass index (BMI) report higher rates of discrimination because of their weight compared to re- ports of racial discrimination of ethnic minorities in some domains [7]. Women are particularly stigmatized due to their weight across multiple sectors, including employment, education, media, and romantic relationships, among others [8]. Importantly, weight stigma is also pervasive in healthcare settings [9], and has been observed among physicians, nurses, medical students, and dietitians [4]. Herein, we first address the obesogenic and health-harming nature of weight stigma, and then provide a discussion of weight stigma specifically in healthcare settings.The Creative Commons Public Domain Dedication waiver. Weight stigma triggers obesogenic processes Common wisdom and certain medical ethicists [10, 11] assert that stigmatizing higher-weight individuals and applying social pressure to incite weight loss improves population health. We argue the opposite. The latest science indicates that weight stigma can trigger physiological and behavioral changes linked to poor metabolic health and increased weight gain [4, 5, 12-14]. In laboratory experiments, when study participants are manipulated to experience weight stigma, their eating increases [15, 16], their self-regulation decreases [15], and their cortisol (an obesogenic hormone) levels are higher relative to controls, particularly among those who are or perceive themselves to be overweight. Additionally, survey data reveal that experiences with weight stigma correlate with avoidance of exercise [17]. The long-term consequences of weight stigma for weight gain, as this experimental and survey work suggests, have also been found in large longitudinal studies of adults and children, wherein self-reported experiences with weight stigma predict future weight gain and risk of having an 'obese' BMI, independent of baseline BMI [18-20]. The harmful effects of weight stigma may even extend to all-cause mortality. Across both the nationally representative Health and Retirement Study including 13,692 older adults and the Midlife in the United States (MIDUS) study including 5079 adults, people who reported experiencing weight discrimination had a 60% increased risk of dying, independent of BMI [21]. The underlying mechanisms explaining this relationship, which controls for BMI, may reflect the direct and indirect effects of chronic social stress. Biological pathways include dysregulation in metabolic health and inflammation, such as higher C-reactive protein, among individuals who experience weight discrimination [22]. In MIDUS and other studies, weight discrimination also amplified the relationship between abdominal obesity and HbA1c, and metabolic syndrome more generally [23, 24]. Longitudinal data from MIDUS also showed that weight discrimination exacerbated the effects of obesity on self-reported functional mobility, perhaps because weight discrimination undermines one's self-concept as a fully functioning, able person [25]. Weight stigma also has profound negative effects on mental health; nationally representative data from the United States show that individuals who perceive that they have been discriminated against on the basis of weight are roughly 2.5 times as likely to experience mood or anxiety disorders as those that do not, accounting for standard risk factors for mental illness and objective BMI [26]. Furthermore, this detrimental effect of weight stigma on mental health is not limited to the United States; weight-related rejection has also been shown to predict higher depression risk in other countries [27]. Importantly, the evidence indicates that the association generally runs from discrimination to poor mental health, rather than vice versa [27]. A rapidly growing set of studies now shows that these associations cannot simply be explained by higher-weight individuals' poorer health or greater likelihood of perceiving weight-related discrimination. In fact, the mere perception of oneself as being overweight, across the BMI spectrum (i.e., even among individuals at a 'normal' BMI), is prospectively associated with biological markers of poorer health, including unhealthy blood pressure, C-reactive protein, HDL cholesterol, triglycerides, glucose, and HbA1c levels [28]. Emerging evidence indicates that this harmful cycle may even be intergenerational, wherein children perceived as overweight by their parents are at greater risk for excess weight gain across childhood [29], independent of the child's actual weight. Collectively, these findings suggest that stigma attached to being 'overweight' is a significant yet unrecognized agent in the causal pathway from weight status to health. Weight stigma in healthcare Healthcare is a setting in which weight stigma is particularly pervasive, with significant consequences for the health of higher-weight patients [30, 31]. A sample of 2284 physicians showed strong explicit and implicit 'anti-fat' bias [32]. High levels of bias are observed even among clinicians specializing in obesity-related issues, with the proportion endorsing explicit 'anti-fat' bias sentiments (e.g., 'Fat people are worthless') increasing in recent years [33]. The nature of healthcare provider bias encompasses endorsement of negative stereotypes of patients with obesity, including terms like 'lazy', 'weak-willed', and 'bad', feeling less respect for those patients, and being more likely to report them as a 'waste of time' [30]. This stigma has direct and observable consequences for the quality and nature of services provided to those with obesity, leading to yet another potential pathway through which weight stigma may contribute to higher rates of poor health. In terms of quality of care and medical decision-making, despite the fact that higher-weight patients are at elevated risk for endometrial and ovarian cancer, some physicians report a reluctance to perform pelvic exams [34] and higher-weight patients (despite having health insurance) delay having them [35]. Higher BMI male patients report that physicians spend less time with them compared to the time they spend with lower BMI patients [36]. Additionally, physicians engage in less health education with higher BMI patients [37].