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Received: 7 May 2021 Revised: 24 July 2021 Accepted: 24 July 2021
DOI: 10.1111/obr.13333

PUBLIC HEALTH

Weight stigma and obesity-related policies: A systematic

review of the state of the literature

Briony Hill1 | Heidi Bergmeier1 | Angela C. Incollingo Rodriguez2 |

3 1 4
Fiona Kate Barlow | Alexandra Chung | Divya Ramachandran |
Melissa Savaglio1 | Helen Skouteris1,5

1
Health and Social Care Unit, School of Public
Health and Preventive Medicine, Monash Summary
University, Melbourne, Victoria, Australia Weight stigma is an important issue colliding with obesity-related policies; both have
2
Psychological & Cognitive Sciences,
population health and social impacts. Our aim was to conduct a systematic review of
Department of Social Science & Policy Studies,
Worcester Polytechnic Institute, Worcester, the peer-reviewed literature that combined the concepts of stigma, obesity, and policy.
Massachusetts, USA
We searched PsycINFO, Medline, Scopus, and Google Scholar for peer-reviewed arti-
3
School of Psychology, University of
Queensland, Brisbane, Queensland, Australia cles amalgamating terms relevant to stigma, obesity, and policy. Of 3219 records iden-
4
Boden Institute, University of Sydney; tified, 47 were included in the narrative synthesis. Two key types of studies emerged:
Weight Issues Network, Sydney, Australia
studies investigating factors associated with support for obesity-related policies and
5
Warwick Business School, The University of
Warwick, Coventry, UK
those exploring policy implementation and evaluation. We found that support for non-
stigmatizing obesity-related policies was higher when obesity was attributed as an
Correspondence
Briony Hill and Helen Skouteris, Health and
environmental rather than individual problem. An undercurrent theme suggested that
Social Care Unit, School of Public Health and views that blame individuals for their obesity were associated with support for punitive
Preventive Medicine, Monash University,
553 St Kilda Road, Melbourne 3004, Australia.
policies for people living in larger bodies. Real-world policies often implicitly condoned
Email: briony.hill@monash.edu; stigma through poor language choice and conflicting discourse. Our findings inform
helen.skouteris@monash.edu
recommendations for policy makers that broader socioecological stigma-reduction
approaches are needed to fully address the issue of weight stigma in obesity-related
policies. Efforts are needed in the research and policy sectors to understand how to
improve the design and support of nonstigmatizing obesity-related policies.

KEYWORDS
obesity, policy, weight stigma

1 | I N T RO DU CT I O N corrected in this version.] The implications of this are numerous.2 In

fact, weight stigma is a recognized risk factor for various adverse
Weight stigma is the phenomenon of bias, discrimination, psychological and physical health issues.2 These can exacerbate
stereotyping, social exclusion, and devaluing based on an individual's stress-related behavioral, emotional, and biological responses that
1
weight. People living in larger bodies (i.e., obesity, typically defined influence further weight gain, including unhealthy eating behavior
by a body mass index of 30 kg/m2 or higher) are almost nine times and reduced energy expenditure.3 Furthermore, people face weight-
more likely to experience weight-based discrimination compared based exclusion across settings such as workplaces, healthcare, and
with individuals living in a body classified as “normal weight” in everyday life.1 Public health consequences of weight stigma
(i.e., typically defined as a body mass index of between 18.5 and include the disregard of societal, environmental, and genetic contrib-
24.9 kg/m2). [Correction added on 1 June 2022, after first online utors to obesity, increased health disparities, and exacerbation of
publication: The “normal weight” in the preceding sentence has been social inequalities.4

Obesity Reviews. 2021;22:e13333. wileyonlinelibrary.com/journal/obr © 2021 World Obesity Federation 1 of 10

https://doi.org/10.1111/obr.13333

2 of 10
Traditionally, policies focused on mitigating population obesity
have centered on education for those living in larger bodies.5 The
implicit assumption here is that lack of knowledge on nutrition and
lifestyle behaviors alone leads to weight gain.4 This approach ascribes
responsibility to individuals living in a larger body, blaming them for
their weight status, thus, reinforcing weight stigma.1 Ten to 15 years
ago, there were calls for obesity prevention efforts to also focus on
policies that target the social and environmental (rather than individ-
ual) factors contributing to the development of obesity.4 For example,
the World Health Organization Global Strategy on Diet, Physical
Activity and Health incorporated recommendations that address indi-
vidual, social, and environmental contexts.6 These recommendations
included marketing restrictions, fiscal policies to influence food con-
sumption, and agricultural policies.6 Important benefits of strategies
that address the structural determinants of obesity include minimizing
the attribution of responsibility for obesity to the individual and
reduced victim blaming.4 Similarly, the Australian Government out-
lined recommendations to improve the well-being of Australians.
These included environmental changes to increase physical activity
and reduce sedentary behavior, promote healthy diets via changes in
food supply, and reduce people's exposure to marketing of unhealthy
food and beverages.7 However, a 2020 report revealed that virtually
no progress had been made towards achieving these goals.8 More
recently, the UK Government's Better Health campaign initiated in
July 2020 to target obesity during COVID-19 focused on individuals
making healthier choices and reducing their calorie intake while neg-
lecting public health approaches, which implies individual responsibil-
ity and reinforces weight stigma.8 In contrast, the new Canadian
Obesity Guidelines 2020 outlines strategies for reducing weight
stigma and bias in clinical practice.9 Concurrently, support for
weight stigma and discrimination reduction policies, such as anti-
bullying laws, have also begun to appear.10,11
Clearly, there has been little progress in sustaining recommenda-
tions and policies to minimize the impact of weight stigma while simul-
taneously tackling factors associated with obesity, although there is
agreement that this should be a priority. In fact, a 2020 international
consensus statement recommended that academics, professionals,
media, public-health authorities, and governments should encourage
education on weight stigma to facilitate a new public narrative about
obesity.12 This consensus statement and the stakeholders identified for
inclusion in the weight stigma narrative highlight the importance of
public support for policies so that policy impact can be realized
10,13
downstream. Factors that increase public policy support include
identifying an appropriate “frame” for obesity (that avoids victim blam-
ing) and mobilizing citizen engagement.13 Understanding such factors is
therefore essential for designing policies that have successful public
health impacts. Following this, there is also a need to evaluate policy
effectiveness to ensure they do not inadvertently cause harm.5
The literature combining weight stigma and obesity-related policies
is currently lacking, so there is a need to consider these two issues in
tandem to drive research forward and lead to population health
changes. Consequently, we set out to understand the state of the litera-
ture (including policies related to the prevention and treatment of
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HILL ET AL.
obesity and policies that reduce or promote discrimination based on
excess weight), with the potential to inform future obesity-related
policies while mitigating the perpetuation of weight stigma. In doing so,
we intended to provide recommendations for practice for both policy
makers and researchers. Previous narrative reviews have explored the
impact of weight stigma and obesity-related policies in isolation.14–16
However, to our knowledge, there is no systematically conducted
review available that explores the relationship between these concepts.
Hence, the aim of this study was to conduct a systematic review of the
peer-reviewed literature that combined the concepts of stigma, obesity,
and policy. Scoping searches revealed a diversity in the way weight
stigma and obesity policy have been approached in research and led us
to devise two broad and exploratory research questions to guide our
review: (1) What are the factors associated with support for obesity-
related policies that might reduce or promote weight stigma? (2) What
are the factors relating to the implementation and evaluation of
obesity-related policies that may reduce or promote weight stigma? We
acknowledged a priori that these research questions were broad, not
exhaustive, and that the literature may reveal other relevant questions
or issues in a field of research still in its infancy.
2 | METHOD
This systematic review was registered on the Open Science
Framework17 prior to screening of articles and has been reported in
accordance with the Preferred Reporting Items for Systematic
Reviews and Meta-Analyses (PRISMA) statement guidelines 2020.18
2.1 | Search strategy
PsycINFO, Medline, Scopus, and Google Scholar (selected as comple-
mentary databases covering psychology, medicine, and broader litera-
ture) were searched in June 2021 for relevant, peer-reviewed articles
published in English between January 2011 and June 2021, combining
the concepts of stigma AND obesity AND policy. The systematic search
strategy was developed in consultation with a research librarian. There
was no limit to geographic location. Grey literature was not searched as
we were not looking for policies themselves, but empirical investiga-
tions of policy and stigma (i.e., what do we know at the empirical
evidence level about weight stigma and obesity related policies?).
Studies were excluded if they did not explicitly examine the relationship
between weight stigma and obesity-related policies (e.g., studies that
explored the framing of obesity and weight stigma, but did not then link
such stigma to policy). The full search strategy is presented in Table S1.
Forward citation searching of all included articles was conducted.
2.2 | Inclusion and exclusion criteria
Inclusion and exclusion criteria were defined according to the partici-
pants, intervention or exposure, comparator, outcome, and study type

HILL ET AL.
(PICOS) framework (Table S2). Eligible studies included those that
reported on obesity-related policy change, manipulation to policy, or
perceptions of policy that linked directly to weight stigma.
Obesity-related policies also encompassed antidiscrimination or anti-
bullying policies that attempted to reduce weight stigma perpetuated
against individuals living in larger bodies. Participants of any
type were eligible, including patient or community populations
(e.g., children, parents, women, adults, and students) and policy stake-
holders (e.g., government and organization directors). If applicable, a
comparator group could include a control, usual care, or an alternative
experimental group. Outcomes were not limited and could include
factors such as behavior change, health/psychosocial outcomes,
perspectives/views of participants, and evaluation/effectiveness
outcomes. Inclusion was limited to primary studies of any type.
Stigma and policy were defined a priori. Stigma was defined as a
pervasive phenomenon promoting widespread bias and discrimina-
tion, stereotyping, social exclusion, and devaluation based on an indi-
vidual's excess weight and included assigning responsibility to an
individual for their obesity or body size (i.e., blaming). Policies were
defined as frameworks, strategies, action plans, policies, strategic
plans, recommendations, or public health and well-being plans that
propose a course or principle of action in the context of government,
schools, healthcare, workplaces, or community settings.
2.3 | Study selection process
After removal of duplicates, records were screened in Covidence.19
Titles and abstracts of all records were screened by one author with
expertise in weight stigma and obesity (BH) and a random 20% of the
records were verified by a second author with expertise in policy and
weight stigma (ACIR or MS). Agreement of >80% was considered
acceptable20; 98% agreement was achieved for title and abstract
screening and 99% agreement for full text screening. All full-text
studies (100%) were independently screened by two authors (BH and
MS). Discrepancies were resolved by discussion. Reasons for
exclusion at the full text stage are presented in Table S3.
2.4 | Assessment of study quality
Study quality was assessed by one author (MS), with a 20% subset
assessed by a second author (AC); 93% agreement was achieved. For
quantitative studies, quality was evaluated via the Centre
for Evidence-Based Management (CEBMa) checklist for surveys,
irrespective of study design.21 This process facilitated ease of compar-
ison across studies with only a single tool required rather than the
multiple required if the tool matching the study design was used.
The CEBMa tool for surveys contains 12 criteria that assesses the
clarity of the question/issue, appropriateness of research method,
method of subject selection, possibility of selection bias, representa-
tiveness of the subjects, prestudy considerations of sample size, satis-
factory response rate, validity and reliability of the questionnaire,
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3 of 10
calculation of statistical significance, reporting of confidence intervals,
and consideration of confounding factors. One criterion (the applica-
bility of the results) was excluded as it was not relevant to this
systematic review.
Qualitative studies were evaluated via the Critical Appraisal Skills
Program (CASP) Qualitative Studies Checklist.22 This tool contains 10
criteria that assess the clarity of research aims, appropriateness of
qualitative research design and data collection method, consideration
of the relationship between researchers and participants, consider-
ation of other ethical issues, quality of data analysis, and statement of
findings. One criterion (the value/applicability of the findings) was
excluded as this was not relevant to this review. For both assessment
tools, each criterion was assessed as “yes,” “no,” or “can't tell.”
2.5 | Data extraction and synthesis
Data were extracted using a piloted template by one author (BH) with
a 20% subsample extracted by a second author (AC) to check reliabil-
ity; 95% agreement was achieved. Disagreements were resolved by
discussion. Information was collected on general details (title, authors,
reference/source, country, year of publication, and funding source),
sample size, study aim, study design, participant characteristics, and
key findings. A narrative synthesis of findings was conducted.
3 | RE SU LT S
3.1 | Study selection
The study selection flow chart is presented in Figure 1. The search
identified 3219 records. After removal of 715 duplicates, 2504 titles
and abstracts were screened, followed by 109 full-text articles.
Forty-seven studies were deemed eligible and included in the
review.
3.2 | Characteristics of included studies
Consistent with the research questions defined a priori, two key
types of studies emerged in the included literature: studies investi-
gating (1) factors associated with policy support (n = 41); and (2)
policy implementation and evaluation (n = 6). Characteristics of
included studies are presented briefly in Tables S8 (factors
associated with policy support) and S9 (policy implementation and
evaluation) and in further detail in Tables S4 and S5. Studies were
primarily experimental in design (n = 17, 36.0%) or surveys/inter-
views (n = 22, 47.0%). One study included both experimental design
and a separate survey,63 and one used a Delphi method.24 Six stud-
ies were evaluations or descriptions of existing policies viewed
through a stigma lens.5,25–29 Sample sizes ranged from 55 for one
experiment24 to 3502 for an online survey.30 In terms of the popu-
lation focus, 32 (68.1%) studies evaluated stigma or policy relevant

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to adulthood or general population overweight or obesity,5,23–53 15
(31.9%) studies were focused on childhood/adolescent obesity or
schools,27,54–66 and one (2.1%) study focused on policies specifically
relevant to women's reproductive health67 (some studies had
multiple populations of interest). Most studies recruited adults,
except six that examined policies and thus did not recruit any par-
ticipants.5,25–29 The majority of studies (n = 30) were conducted in
the United States (63.8%), four (8.5%) in the United King-
dom,26,31,43,56 two (4.3%) in Denmark,30,41 two in Australia,37,39 and
38 27 36
one each in Germany, Canada, and New Zealand. One study
was a comparison across Belgium, Denmark, Italy, Poland, and the
United Kingdom,41 whereas two studies involved a cross-country
comparison of the United States, Canada, Iceland, and Australia.47,62
5
Policy evaluations included the European Union, Australia/France/
Switzerland,25 Canada,27 and England/France/Germany Scotland.29
There were 41 studies that explored obesity-related policy sup-
port, which were grouped into the following themes: 25 (61.0%)
studies focused on weight bias (e.g., causal attributions of obesity
or assigning individual or societal responsibility for obesity),
explored in relation to policies focused on the prevention and
treatment of obesity; 12 (29.3%) studies focused on ant-
idiscrimination or antibullying weight-based policies that attempted
to reduce weight stigma11,30,38,43,47,48,50,59,60,61,63,65,67; of the
remaining studies, two (5.1%) covered both causal attribution and
antidiscrimination/bullying,49,62 one study focused on weight-based
32
prejudice, and one on weight stigma in health research and
practice.24 Seven (17.1%) studies evaluated media or news articles
(real or fake).33,34,39,51,58,65,67
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HILL ET AL.
FIGURE 1 PRISMA flowchart of studies in
review
3.3 | Study quality
The quality assessment of the included studies is presented in
Tables S6 (quantitative) and S7 (qualitative). All 44 quantitative stud-
ies had clear aims and adopted appropriate research methodology to
address their research questions. Participant recruitment strategies
were generally clearly described (n = 28), but 33 studies were non-
randomized, which likely introduced selection bias. Six studies
reported prestudy considerations of sample size, whereas 19 acknowl-
edged that their sample was representative of the population of inter-
est. The majority of studies provided no or insufficient information to
determine the response rate (n = 13 studies achieved a satisfactory
response rate). Questionnaires were valid and reliable in 14 studies,
and statistical significance was reported in 36 studies. The three quali-
tative studies were high quality, with clear research aims, appropriate
use of qualitative methodology and data collection, sufficiently
rigorous data analysis, and clear statements of the findings.27,29,40
3.4 | Research question 1: Factors associated with
policy support
The first research question was explored in 41 studies, which dis-
cussed a broad range of obesity-related policies that can reduce or
promote weight stigma, and the factors associated with support for
such policies. These included policies related to taxing of unhealthy
foods, menu labeling, advertising restrictions, food/beverage industry
regulations, behavior-based policies, and polices targeted towards

HILL ET AL.
individuals living with overweight or obesity.31,32,55 The stigmatizing
or nonstigmatizing nature of policies was not clearly outlined in many
included studies. Exceptions included antidiscrimination policies based
on weight (nonstigmatizing),38,47,48,60,63 policies that denied women
67
living with obesity access to fertility treatment (stigmatizing), puni-
tive warning labels on soft drinks that negatively depicted obesity
37
using graphic imagery (stigmatizing), and punitive price-raising poli-
cies that punish people for living with obesity (stigmatizing).32,34,44,58
3.4.1 | Studies of weight bias predictors of obesity-
related policies focused on the prevention or treatment
of obesity
Most studies that were focused on weight bias predictors of preven-
tion and treatment-related obesity policies explored causal attribu-
tions and assigning responsibility for obesity (n = 25). In general,
support for obesity-related policies was higher when individuals
agreed more strongly with attributions for obesity that were beyond
personal control (e.g., obesity can be attributed to environmental
availability of unhealthy foods) when compared with attributing obe-
sity to lack of willpower and individual responsibility.31,40,41,45,56 For
41
example, Mazzocchi et al. reported that attributing obesity to the
food supply environment was associated specifically with support for
healthy eating policies. However, these findings were not universally
supported, perhaps due to differences in the conceptualization of
underpinning theory used to determine attributions of responsibility
for obesity. For example, McGlynn and McGlone42 reported that
assigning agency for obesity to people (rather than to the condition of
obesity itself—blaming the person not the condition) was associated
with higher support for public policies to reduce obesity.
These discrepant findings may also be related to other factors,
such as the types of policies (e.g., stigmatizing or nonstigmatizing)
attracting support or the characteristics of the populations. Thibodeau
52
et al. evaluated support for policies designed to protect people living
in larger bodies (e.g., to extend the same legal protections and bene-
fits offered to people with other physical disabilities) compared with
policies that penalized people for their excess weight (e.g., to require
health insurers to charge higher premiums for policy-holders who are
classified as overweight). They found that environmental or societal
causal attributions were associated with support for protective poli-
cies, and the individual causal attributions were associated with penal-
izing policies. In a different study, the same researchers reported that
higher levels of empathy were associated with increased support for
societal level policies (e.g., increasing taxes to fund educational
interventions) compared with punitive individual incentives
(e.g., higher health insurance premiums) that could be considered
more stigmatizing.53 Another study reported an interaction between
environmental attribution for obesity and self-efficacy for weight loss,
where individuals with higher self-efficacy were more likely to support
23
food-related policies aimed at preventing obesity.
Individual attributions for obesity or holding negative views of
people living with obesity were associated with support for policies
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5 of 10
that negatively impacted/stigmatized people living in larger bodies in
most studies that investigated this relationship specifically.33,34,56,58
Similarly, willingness to pay taxes for healthy eating policies was
higher when obesity was ascribed to the supply environment.41
However, Niederdeppe et al.44 reported findings that contradicted
the general consensus, where beliefs about individual responsibility
were not associated with support for price-raising policies.
There also appeared to be differences in the impact of attribution
framing (how messages portray the responsibility of obesity) on men
and women.35 In an experimental study, attribution framing had no
effect on policy support for women. However, men exposed to the
individual frame (ascribing responsibility to individuals for their obe-
sity) showed less support for policies than when exposed to the frame
depicting obesity as beyond an individual's control.35 Differences also
appear to be related to characteristics such as political affiliation and
parenting status. For example, in the study by Gendall et al.,36 people
more likely to support policies that were focused on individuals were
more likely to be politically conservative, male, and less likely to be
parents.
In many of the experimental studies incorporated above, media
frames with variable attributions for obesity were manipulated.
Indeed, Saguy et al.51 concluded that news reports on population level
obesity commonly lay blame for obesity on individual behavior, which
may unintentionally activate prejudice. One study also investigated
the views of people living with obesity on news media guidelines.39
They reported that when people were not in favor of media reporting
guidelines on obesity stigma and body diversity, it placed responsibil-
ity on the individual to moderate their own interactions with the
media. Additionally, they reported that news media has the potential
to have a positive influence on prompting people to take action to
address their weight.39
One study focused on the associations between weight-based
prejudice and attitudes towards obesity-reducing public policies.32 In
this survey of US residents, “antifat” prejudice was a significant pre-
dictor of support for punitive weight-based polices, even after
controlling for age, gender, body mass index, ethnicity, education and
political conservatism.32 Further, biological causal attributions of
obesity were positively associated with weight bias internalization
and support for food-related policy measures.23,56 Specifically, men
(but not women) exposed to causes of obesity that were framed as
internal/uncontrollable (genetics) showed greater support for food-
related policy measures than men exposed to frames of obesity as an
individual choice.35 Agreement with genetic attribution framing was
also associated with higher support for healthy lifestyle campaigns
and weight loss treatments being free or government funded.31
Some studies focused specifically on policies that pertained to
children, adolescents or schools. Overall, as with adult or general
policies, individualizing the problem of childhood obesity was
associated with lower support for obesity prevention policy.54,56 As
with adult policies, these discrepancies may be related to
differences in gender (women more likely to be supportive59,62) and
political affiliation (moderate and liberal voters more likely to be
supportive59).

6 of 10
Lastly, one study framed messages about obesity from a child ver-
sus an adult perspective.64 The authors found that people blamed
children for obesity less than they did adults, which in turn predicted
increased support for policies aimed at reducing childhood obesity.
Other studies reported that higher attribution of parental responsibil-
ity for obesity was associated with increased support for policies
57,66
targeted at schools.
3.4.2 | Studies focused on antidiscrimination or
antibullying weight-based policies to reduce weight
stigma
Obesity-related antidiscrimination policies that attempted to reduce
weight stigma included laws such as legal protection of people living
with obesity (such as that for people with physical disabilities), laws
against weight-based discrimination at the general population
(i.e., state or federal) and workplace levels, and strategies to address
weight-based bullying or victimization at the general population and
11,43,48–50,62
school levels. In general, antidiscrimination measures such
as polices and legislation to prohibit weight-based victimization
against adults were supported at moderate to high levels (40%–
30,38,49
80% ), with indications that policy support is increasing over
time.11,30,50
Personal characteristics were associated with support for ant-
idiscrimination or bullying policies. For instance, women were consis-
30,38,47,48
tently found to be more supportive than men except in two
studies where there were no gender differences; note that partici-
pants in both of these studies were recruited through the same survey
sampling company.11,50 Support for antidiscrimination measures was
30,38,47,48
also greater for people with lower education or income,
except in the same two studies noted above.11,50 Additionally, a lib-
eral (versus conservative) political affiliation was associated with sup-
port for these policies.11,30,47 Higher weight status and greater
weight-related self-stigma were also associated with support for ant-
idiscrimination policies.38,43,47,48
Regarding the protection of children through antibullying or
antiweight-based discrimination policies, there was common agree-
ment among parents, educators, the general population, and eating
disorder health professionals that antibullying policies should be
implemented at both the school and state legislative level to minimize
weight-based victimization.11,59–63 One study also highlighted support
for policy actions that aimed to regulate television content
(e.g., increase programs that portray children of diverse body sizes
65
eating healthy food and being physically active).
Personal characteristics associated with greater support for the
antibullying or weight-based discrimination policies that protect chil-
dren were similar to those associated with adult-related policies:
30,59–62
women, people who had experienced or witnessed a family
member experiencing weight-based victimization,58 and liberal politi-
11,61,65
cal affiliates, were more likely to be supportive of policies
protecting children. Reported associations for ethnicity were con-
11,59–62
flicting. In contrast to adult laws, people with higher education
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HILL ET AL.
were more supportive of child-related antibullying policies,60,61 while
findings for income were inconsistent.11,61
Finally, one study focused on polices specific to women, namely,
policies with the purpose of denying women living with overweight or
obesity fertility treatment.67 In this study, participants viewed a stig-
matizing image of a couple that lived with obesity. Compared with
participants who were shown a nonstigmatizing image, these partici-
pants were more likely to support policies that deny women living in
larger bodies fertility treatment. This association was mediated by
perceptions of medical risk for women with obesity seeking fertility
treatment, such that the stigmatizing image increased perception of
medical risk, which increased support for denying fertility
treatment.67
3.4.3 | Other studies
One study investigated weight stigma in the context of health
research and practice.24 This Delphi study aimed to establish expert
consensus on how public health professionals can address weight
stigma in their work, including the importance of varying items for
inclusion in a position statement that would be designed for this pur-
pose. Priorities included defining the problem of weight stigma in
research and practice and identifying concrete strategies for reducing
weight stigma at the population level. Overall, it was recommended
that a shift in focus from weight to health occur, but consensus on
how to do this could not be reached.24
3.5 | Research question 2: Policy implementation
and evaluation
The second broad research aim for this review sought to identify
factors associated with the implementation and evaluation of obesity-
related policies that reduce or promote weight stigma. Six studies
provided an evaluation or description of existing obesity-related
policies incorporating a stigma lens and hence contributed to this
aim.5,25–29 These studies evaluated a range of policies related to obe-
sity, mainly across Europe, with one study also including policies from
Australia,25 and one study examining policies from Canada.27 Dual
responsibility for obesity was seen across the policies, recognizing a
mixture of both individual responsibility and environmental/social
determinants of health playing a role in the development of obe-
sity.5,25–29 The extent that either individual or environmental respon-
sibility was emphasized differed across countries. At times, the
messages were seen to be conflicting; by emphasizing human rights to
choose their own behaviors, the environmental responsibility was
diminished.26
Explicit mentions of stigma in the policies were few.5,29 A French
policy described the stigma and discrimination attached to obesity
and outlined a goal to fight discrimination; however, the policy did
not articulate how to reduce this stigma.29 Nevertheless, the included
studies highlighted that stigmatizing language and portrayals of

HILL ET AL.
people living with obesity invoked stigma without needing to be
explicit.5,26,27,29 It was noted by Hartlev5 that individuals living in
larger bodies were frequently seen as blameworthy and hence
policies that did not address language use were not combating stigma
and perhaps implicitly supporting stigma. Frequently, lack of thought-
ful wording implied not only that individuals living with obesity were
responsible for their weight and that they were lacking self-control
or lazy, but that they were also responsible for the broader
societal impacts associated with obesity.5,26,27 Vallgarda29 also
highlighted that some policies implied that people living with obesity
were harming the economy. Hann et al. 26
and Ramos et al. 27
surmised that when policies are focused on individual-level
solutions and fail to reduce obesity at the population level, the
stigmatized group (i.e., people living in larger bodies) are viewed as
having failed to heed the proscriptions, rather than the policy being
ineffective.
4 | DISCUSSION
Building on previous narrative reviews, this systematic review of the
literature combined the concepts of stigma, obesity and policy.
The majority of the literature explored factors associated with public
support for obesity-related policies (first research question), where
the focus was on the controllability of weight. It was found that
support for obesity-related policies focused on prevention or treat-
ment was higher when obesity was attributed as an environmental
rather than individual problem, with the latter seeming to promote
weight stigma. We also identified that the association between
causal attributions for obesity (implying stigma) and support for
obesity-related policies was largely related to personal characteris-
11,30,47
tics (e.g., gender, political affiliation, and parenting status),
with an undercurrent suggesting that individual attributions for
obesity may be associated with support for punitive policies for
people living with obesity, such as higher taxes and health insurance
costs, and thus may perpetuate weight stigma.38,48 The same
pattern emerged in literature addressing antiweight-based discrimi-
nation policies.
Our findings indicate a need to increase individuals' understand-
ing of the environmental contributors to obesity, both in general and
for groups with specific characteristics. Perhaps, understanding the
factors associated (positively and negatively) with policy support may
help to identify opportunities for targeting misconceptions relating to
obesity development and increase support. For example, as proposed
10
by social consensus theory, people tend to form views that conform
to the beliefs of those they associate with and/or “higher status”
groups they wish to join. This may explain the lack of support for anti-
weight stigma policies among people with certain personal
characteristics, such as male gender, lower education status, and polit-
ical conservatism.11,30,47 Indeed, efforts to evoke changes in
health-promoting policy support among groups with traditionally
lower support may need to focus on broader societal level changes,
such as social norms and attitudes towards individuals of varying body
1467789x, 2021, 11, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/obr.13333 by University Of Texas - Ham/Tmc, Wiley Online Library on [07/11/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
7 of 10
size and shape. Interestingly, while the media and public messaging
could be seen to play an important role in changing social norms and
attitudes around obesity,68,69 our findings indicated a pervasive view
that individuals are responsible for their own media consumption. In
contrast, media campaigns focused on social and health issues have
been successful at increasing public support and policy.70 Further
research is needed to delineate whether the media are likely to play a
key role in advancing support for non-stigmatizing weight-related
policies.
The evaluation of policies that have been implemented in the
“real world” (second research question) showed that, while both indi-
vidual and environmental responsibility are acknowledged, they are
often implicitly condoning stigma through poor language choice and
conflicting discourse. For example, Hann26 points out that current
guidelines oversimplify energy balance (“calories in-calories out”) in
their approach to weight management. By not considering neurophys-
iological mechanisms involved in processing different food types
(including hormonal responses involved in energy regulation), this
oversimplification is at odds with the known complexity of obesity,71
and reinforces unhelpful stereotypes often attributed to individuals
living with obesity, such as “laziness.”26 Enacting public health policies
for the prevention and treatment of obesity requires understanding
and consideration of the multifactorial causes of obesity across indi-
71
vidual and environmental contexts, where on one hand individual
behaviors can sometimes directly reduce or exacerbate risk of exces-
sive weight gain, yet on the other hand, individual behaviors are
deeply intertwined with and influenced by broader socioecological
factors.72,73 This complexity has been explicated in the Health Stigma
and Discrimination Framework, highlighting the socioecological con-
text that surrounds the perpetuation and experiences of weight
stigma.74 This discord in messaging may present challenges for policy
makers to address. However, it emphasizes the work that is urgently
needed to break down silos across sectors, structures and systems to
develop policies that enable—rather than impede—equitable opportu-
nities for healthy lifestyles.
Socioenvironmental opportunities for healthy lifestyles are typi-
cally diminished and obesity prevalence is higher among marginalized
groups.75,76 Therefore, enacting policies that focus on addressing
weight stigma may require incorporating a health equity lens that con-
siders social determinants of health, rather than targeting strategies
that perpetuate inequity and individual blame.75,77 Currently, not only
do many strategies fail to address underlying factors maintaining and
even exacerbating determinants of public health, including excess
body weight, they may run the risk of increasing harm.8,78 More work
is needed to understand how to develop obesity policies that enable
systems, structures, and sectors to effectively address weight stigma.
Finally, recognizing broader systems and structures that maintain and
perpetuate stigma may also challenge the public and policy makers to
consider more deeply rooted mechanisms driving disparate public
health outcomes, including racism and racism-related stressors, via
their impact on equitable access to obesity prevention.77,79 However,
currently this intersectionality framework is understudied and thus,
poorly understood.

8 of 10
4.1 | Limitations and strengths
It is noted that this study was limited by the potential shortcomings of
excluding grey literature, which may mean that potentially relevant
information was not included, yet it was intended to only synthesize
the empirical peer-reviewed evidence to date. Additionally, the search
yielded a vast number of different types of terminology, with nuances
applicable to the various terms used in defining factors associated with
obesity, which included causal attributions and responsibility for obesity
across the individual, environment, or industry; assigning agency; and
use of message framing. It is appreciated that these differences are
difficult to capture when presenting a synthesis of the literature, but
nonetheless, a comprehensive inclusion approach was adopted. The
findings should also be interpreted in light of the caveat that study
quality was not optimal in many reviewed papers, albeit quality scores
were lower based on factors expected in the included study designs.
This perhaps also highlights a limitation across the published studies in
this field, which may be a downstream consequence of weight stigma
literature, where little research prioritizes addressing gaps in knowledge
on weight stigma at the policy level. In spite of this, our broad defini-
tions of stigma in the context of obesity that attempted to be inclusive
in nature is a notable strength of this review. Moreover, the systematic
review format provided a comprehensive and high-level synthesis.
4.2 | Recommendations for future research and
policy action
Although there were nuances in the literature reviewed, this study
points to several key opportunities for future research:
1. Investigating ways to increase individuals' understanding of the
environmental contributors to obesity both in general and for
groups with specific characteristics that are prone to weight-
stigmatizing beliefs. This might include exploring and addressing
broader socioecological factors, such as social norms and attitudes
towards obesity. This knowledge has the potential to reduce
weight stigma overall, while increasing support for obesity-related
policies that avoid weight stigma.
2. Developing further understanding of the role of the media in
obesity portrayals and how this can be leveraged to reduce stigma
and promote policy support in the context of obesity.
3. Investigating ways to improve the wording and language used in
policies so as to reduce the potential for stigma to be explicitly or
implicitly promulgated through health promoting policies.
Although it is clear further research is needed, the discussion
highlights some key opportunities for policy makers to act now in
working towards the mitigation of weight stigma in obesity-related
policies. These are:
1. Recognizing the multilevel socioecological influences that shape
people's health, well-being and weight status in the development
1467789x, 2021, 11, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/obr.13333 by University Of Texas - Ham/Tmc, Wiley Online Library on [07/11/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
HILL ET AL.
of policies.64 To achieve this, working towards reducing the silos
of industry, government, and consumers so as to reduce inequity
in policy targets may be prudent. For example, this may
require codesigning solutions that incorporate multidisciplinary
and cross-sector perspectives, in partnership with people with
lived experience of weight issues.
2. To begin exploring how the evidence identified in this review and
in future research can be integrated into future policies. An
example could be changing the discourse regarding individual attri-
butions for obesity and blame in policy documents. This could
assist with understanding the impact a policy may have on an indi-
vidual living in a larger body and how any changes made will suit
the needs of all stakeholders.
We acknowledge much of this work is underway in the
broader obesity-policy space.80 We are now calling for a stigma
lens to be applied readily and consistently to obesity-related
policies to optimize their support, uptake and effectiveness moving
forward.
5 | CONC LU SION
This systematic review has identified a complexity in the literature
that has explored the concepts of stigma, obesity and policy. The
findings suggest that broader socioecological stigma-reduction
approaches may be needed to fully address the issue of weight
stigma in obesity-related policies. These approaches may be able to
increase policy support through reducing views that blame individ-
uals solely for their obesity. It was also identified that there is a
need to improve the way obesity-related policies are written so as
to reduce actual and implied stigma. Research and policy maker
action, as depicted in the suggestions above, can contribute to
reducing weight stigma in the development of and support for
obesity-related policies. This action has the potential to further
reduce the development and exacerbation of obesity in stigmatized
individuals and increase policy effectiveness, which may have broad
downstream implications for health and well-being for people living
in larger bodies.
FUNDING STATEMENT
This work was funded by the NHMRC Centre of Research Excellence
in Health in Preconception and Pregnancy (APP1171142).
CONFLIC T OF INT ER E ST
The authors declare that there are no conflicts of interest to disclose.
OR CID
Briony Hill https://orcid.org/0000-0003-4993-3963
Angela C. Incollingo Rodriguez https://orcid.org/0000-0003-1609-
4163
Divya Ramachandran https://orcid.org/0000-0001-6311-9795
Helen Skouteris https://orcid.org/0000-0001-9959-5750

HILL ET AL.
RE FE R ENC E S
1. Brewis A, Sturtzsreetharan C, Wutich A. Obesity stigma as a globaliz-
ing health challenge. Global Health. 2018;14(20):1-6.
2. Prunty A, Clark MK, Hahn A, Edmonds S, O'Shea A. Enacted weight
stigma and weight self-stigma prevalence among 3821 adults. Obes
Res Clin Pract. 2020;14(5):421-427.
3. Tomiyama AJ. Weight stigma is stressful. A review of evidence for
the cyclic obesity/weight-based stigma model. Appetite. 2014;82:
8-15.
4. Puhl RM, Heuer CA. Obesity stigma: important considerations for
public health. Am J Public Health. 2010;100(6):1019-1028.
5. Hartlev M. Stigmatization as a public health tool against obesity-a
health and human rights perspective. Eur J Health Law. 2014;21(4):
365-386.
6. World Health Organization. Global strategy on diet, physical activity
and health—2004. May 26, 2004. Accessed February 15, 2021. Avail-
able at: https://www.who.int/publications/i/item/9241592222
7. Obesity Policy Coalition. Obesity in Australia: A decade of inaction.
Evaluating 10 years of government (in)action against the National Pre-
ventative Health Taskforce’s obesity policy recommendations. Victoria,
Australia: Obesity Policy Coalition; 2020. https://www.opc.org.au/
downloads/10-years/OPC_InAction_Report_FINAL.pdf. Accessed
February 15, 2021.
8. UK policy targeting obesity during a pandemic—the right approach?
Nat Rev Endocrinol. 2020;16:1-2.
9. Wharton S, Lau DCW, Vallis M, et al. Obesity in adults: a clinical prac-
tice guideline. CMAJ. 2020;192(31):E875-E891.
10. Pearl RL. Weight bias and stigma: public health implications and struc-
tural solutions. Soc Iss Policy Rev. 2018;12(1):146-182.
11. Puhl RM, Suh Y, Li X. Improving anti-bullying laws and policies to pro-
tect youth from weight-based victimization: parental support for
action. Paediatric Obes. 2017;12(2):14-19.
12. Rubino F, Puhl RM, Cummings DE, et al. 2020Joint international con-
sensus statement for ending stigma of obesity. Nat Med. 2020;26(4):
1-13.
13. Huang T, Cawley JW, Ashe M, et al. Mobilization of public support
for policy actions to prevent obesity. Lancet. 2020;385(9985):
2422-2431.
14. Lobstein T, Neveux M, Landon J. Costs, equity and acceptability of
three policies to prevent obesity: a narrative review to support policy
development. Obes Sci Pract. 2020;6(5):562-583.
15. Puhl RM, Himmelstein MS, Pearl RL. Weight stigma as a psychosocial
contributor to obesity. Am Psychol. 2020;75(2):274-289.
16. Wu Y, Berry DC. Impact of weight stigma on physiological and psy-
chological health outcomes for overweight and obese adults: a sys-
tematic review. J Adv Nurs. 2017;74(5):1030-1042.
17. Centre for Open Science. OSF Home. 2011, updated 2021. Accessed
February 15, 2021. https://osf.io/
18. Page M, McKenzie J, Bossuyt P, et al. The PRISMA 2020 statement:
an updated guideline for reporting systematic reviews. BMJ. 2021;
372(71):1-9.
19. Veritas Health Innovation. Covidence systematic review software,
Melbourne, Australia: Veritas Health Innovation. Updated February
4, 2019. Accessed February 15, 2021. Available at www.covidence.org
20. Nevis IF, Sikich N, Ye C, Kabali C. Quality control tool for screening
titles and abstracts by second reviewer (QCTSTAR). J Biom Biostats.
2015;6(12):1-15.
21. Centre for Evidence Based Management. Critical Appraisal Checklist
for Cross-Sectional Study. July, 2014. Accessed February 15, 2021.
Available at https://www.cebma.org
22. Critical Appraisal Skills Program (CASP). CASP Qualitative Studies
Checklist. 2018. Accessed February 15, 2021. Available at https://
casp-uk.net/casp-tools-checklists/
23. Pearl RL, Lebowitz MS. Beyond personal responsibility: effects of
causal attributions for overweight and obesity on weight-related
1467789x, 2021, 11, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/obr.13333 by University Of Texas - Ham/Tmc, Wiley Online Library on [07/11/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
9 of 10
beliefs, stigma, and policy support. Psychol Health. 2014;29(10):1176-
1191.
24. Hart LM, Ferreira KB, Ambwani S, Gibson EB, Austin SB. Developing
expert consensus on how to address weight stigma in public health
research and practice: a Delphi study. Sigma Health. 2020;100(6):
1019-1028.
25. Patchett AD, Yeatman HR, Johnson KM. Obesity framing for health
policy development in Australia, France and Switzerland.
Health Promot Int. 2016;31(1):83-92.
26. Hann A, Frawley A, Spedding G. Not very NICE: deviance, stigma and
nutritional guidelines related to health weight and obesity. Int J Health
Plann Mgmt. 2017;32(4):416-432.
27. Ramos Salas X, Forhan M, Caulfield T, Sharma AM, Raine K. A critical
analysis of obesity prevention policies and strategies. Can J Public
Health. 2018;108(5–6):e598-e608.
28. Vallgarda S, Nielsen M, Hartlev M, Sandoe P. Backward- and forward-
looking responsibility for obesity: policies from WHO, the EU and
England. Eur J Public Health. 2015;25(5):845-848.
29. Vallgarda S. Governing obesity policies from England, France,
Germany and Scotland. Soc Sci Med. 2015;147:317-323.
30. Suh Y, Puhl R, Liu S, Millei F. Support for laws to prohibit weight dis-
crimination in the United States: public attitudes from 2011 to 2013.
Obesity. 2014;22(8):1872-1879.
31. Beeken RJ, Wardle J. Public beliefs about the causes of obesity and
attitudes towards policy initiatives in Great Britain. Public Health Nutr.
2013;16(12):2132-2137.
32. Berg MB, Lin L, Hollar SM, Walker SN, Erickson LE. The relationship
between weight-based prejudice and attitudes towards obesity-
reducing public policies. Anal Soc Issues Pub Policy. 2016;16(1):125-142.
33. Frederick DA, Saguy AC, Sandhu G, Mann T. Effects of competing
news media frames of weight on antifat stigma, beliefs about weight
and support for obesity-related public policies. Int J Obes (Lond).
2016;40(3):543-549.
34. Frederick DA, Tomiyama AJ, Bold JG, Saguy AC. Can she be healthy
at her weight? Effects of news media frames on antifat attitudes,
dieting intentions, and perceived health risks of obesity. Stigma
Health. 2020;5(3):247-257.
35. Garbarino E, Henry P, Kerfoot S. Using attribution to foster public
support for alternative policies to combat obesity. Eur J Marketing.
2018;52(1):418-438.
36. Glendall P, Hoek J, Taylor R, Mann J, Krebs J, Parry-Strong A. Should
support for obesity interventions or perceptions of their perceived
effectiveness shape policy. Aust NZ J Publ Health. 2015;39(2):172-176.
37. Hayward L, Vartanian L. Potential unintended consequences of
graphic warning labels on sugary drinks: do they promote obesity
stigma? Obes Sci Prac. 2019;5(4):333-341.
38. Hilbert A, Hubner C, Schmutzer G, Danielsdottir S, Brahler E, Puhl R.
Public support for weight-related antidiscrimination laws and policies.
Obes Facts. 2017;10(2):101-111.
39. Holland K, Blood RW, Thomas SL, Lewis S. Challenging stereotypes
and legitimating fat: an analysis of obese people's views on news
media reporting guidelines and promoting body diversity. J Sociol.
2013;51(2):431-445.
40. Lund TB, Nielsen MEJ, Sandoe P. In a class of their own: the
Danish public considers obesity less deserving of treatment
compared with smoking-related diseases. Eur J Clin Nutr. 2015;69(4):
514-518.
41. Mazzocchi M, Cagnone S, Bech-Larsen T, et al. What is the public
appetite for healthy eating policies? Evidence from a cross-European
survey. Health Econ Policy Law. 2015;10(3):267-292.
42. McGlynn J, McGlone M. Desire or disease? Framing obesity to influ-
ence attributions of responsibility and policy support. Health
Commun. 2019;34(7):689-701.
43. Meyer J, Ruyter K, Grewal D, Cleeren K, Keeling D, Motyka S. Cate-
gorical versus dimensional thinking: improving anti-stigma campaigns

10 of 10
by matching health message frames and implicit worldviews. Acad
Mark Sci. 2020;48(2):222-245.
44. Niederdeppe J, Porticella N, Shapiro MA. Using theory to identify
beliefs associated with support for policies to raise the price of high-
fat and high-sugar foods. J Health Commun. 2012;17(1):90-104.
45. Niederdeppe J, Shapiro MA, Kim HK, Bartolo D, Porticella N.
Narrative persuasion, causality, complex integration, and support for
obesity policy. Health Commun. 2014;29(5):431-444.
46. Niederdeppe J, Roh S, Shapiro MA. Acknowledging individual respon-
sibility while emphasizing social determinants in narratives to pro-
mote obesity-reducing public policy: a randomized experiment. PLOS
one. 2015;10(2):1-11.
47. Puhl RM, Heuer CA. Public opinion about laws to prohibit weight dis-
crimination in the United States. Obesity. 2011;19(1):74-82.
48. Puhl RM, Heuer CA, Sarda V. Framing messages about weight dis-
crimination: impact on public support for legislation. Int J Obesity.
2011;35(6):863-872.
49. Puhl RM, Latner JD, O'Brien KS, Luedicke J, Danielsdottir S, Salas XR.
Potential policies and laws to prohibit weight discrimination: public
views from 4 countries. Milbank Quarterly. 2015;93(4):691-731.
50. Puhl RM, Suh Y, Li X. Legislating for weight-based equality: national
trends in public support for laws to prohibit weight discrimination. Int
J Obes. 2016;40(8):1320-1324.
51. Saguy AC, Frederick D, Gruys K. Reporting risk, producing prejudice:
how news reporting on obesity shapes attitudes about health risk,
policy, and prejudice. Soc Sci Med. 2014;111:125-133.
52. Thibodeau PH, Perko VL, Flusberg SJ. The relationship between nar-
rative classification of obesity and support for public policy interven-
tions. Soc Sci Med. 2015;141:27-35.
53. Thidobeau PH, Uri R, Thompson B, Flusberg SJ. Narratives for obe-
sity: Effects of weight loss and attribution on empathy and policy sup-
port. Health Educ Behav. 2017;44(4):638-647.
54. Barry CL, Brescoll VL, Gollust SE. Framing childhood obesity: how
individualizing the problem affects public support for prevention. Polit
Psychol. 2013;34(3):327-249.
55. Barry CL, Gollust SE, McGinty EE, Niederdeppe J. Effects of messages
from a media campaign to increase public awareness of childhood
obesity. Obesity. 2013;22(2):466-473.
56. Chambers SA, Traill WB. What the UK public believes causes obesity,
and what they want to do about it: a cross-sectional study. J Public
Health Pol. 2011;32(4):430-444.
57. Clemons RS, McBeth MK, Kusko E. Understanding the role of pollicy
narratives and the public policy arena: obesity as a lesson in public
policy development. World Med Health Policy. 2012;4(2):1-26.
58. Frederick DA, Saguy AC, Gruys K. Culture, health and bigotry: how
exposure to cultural accounts of fatness shape attitudes about health
risk, health policies, and weight-based prejudice. Soc Sci Med. 2016;
165:271-279.
59. Puhl RM, Luedicke J. Parental support for policy measures and
school-based efforts to address weight-based victimization of over-
weight youth. Int J Obes. 2014;38(4):531-538.
60. Puhl RM, Neumark-Sztainer D, Austin B, Luedicke J, King KM. Setting
policy priorities to address eating disorders and weight stigma: views
from the field of eating disorders and the US general public. BMC
Public Health. 2014;14(524):1-10.
61. Puhl RM, Luedicke J, King KM. Public attitudes about different types
of anti-bullying laws: results from a national survey. J Public Health
Pol. 2015;36(1):95-109.
62. Puhl RM, Latner JD, O'Brien K, Luedicke J, Forhan M, Danielsdottir S.
Cross-national perspectives about weight-based bullying in youth:
nature, extent and remedies. Paediatric Obesity. 2015;11(4):241-250.
63. Puhl RM, Neumark-Sztainer D, Austin B, Suh Y, Wakefield D. Policy
actions to address weight-based bullying and eating disorders in
schools: views of teachers and school administrators. J School Health.
2016;86(7):507-515.
1467789x, 2021, 11, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/obr.13333 by University Of Texas - Ham/Tmc, Wiley Online Library on [07/11/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
HILL ET AL.
64. Skurka C. Communicating inequalities to enhance support for
obesity-prevention policies: the role of social comparisons, age
frames, and emotion. Health Commun. 2019;34(2):227-237.
65. Suh Y, Puhl R, Liu S, Milici FF. Parental support for policy actions to
reduce weight stigma toward youth in schools and children's television
programs: trends from 2011 to 2013. Child Obes. 2014;10(6):533-541.
66. Wolfson JA, Gollust SE, Niederdeppe J, Barry CL. The role of parents
in public views of strategies to address childhood obesity in the
United States. Millbank Quarterly. 2015;93(1):73-111.
67. Brochu PM, Pearl RL, Puhl RM, Brownell KD. Do media portrayals of
obesity influence support for weight-related medical policy? Health
Psychol. 2014;33(2):197-200.
68. Hoyt C, Burnette J, Auster-Gussman L. “Obesity is a disease”: exam-
ining the self-regulatory impact of this public-health message. Psych
Sci. 2014;25(4):997-1002.
69. Lewis S, Thomas SL, Hyde J, Castle D, Blood RW, Komesaroff PA. “I
don't eat a hamburger and large chips every day!” A qualitative study
of the impact of public health messages about obesity on obese
adults. BMC Public Health. 2010;10(309):1–9.
70. Christensen A, Meyer M, Dalum P, Kraup AF. Can a mass media cam-
paign raise awareness of alcohol as a risk factor for cancer and public
support for alcohol-related policies? Prev Med. 2019;126:1-7.
71. Nutter S, Alberga AS, MacInnis C, Ellard JH, Russell-Mayhew S. Fram-
ing obesity a disease: indirect effects of affect and controllability
beliefs on weight bias. Int J Obes (Lond). 2018;42(10):1804-1811.
72. Australian Public Service Commission. Changing behaviour: a public policy
perspective. June 12, 2018. Accessed February 25, 2021. Available at
https://www.apsc.gov.au/changing-behaviour-public-policy-perspective
73. Ramos Sales X, Alberga AS, Cameron E, et al. Addressing weight bias
and discrimination: moving beyond raising awareness to creating
change. Obes Rev. 2017;18(11):1323-1335.
74. Stangl AL, Earnshaw VA, Logie CH, et al. The health stigma and dis-
crimination framework: a global, crosscutting framework to inform
research, intervention development, and policy on health-related stig-
mas. BMC Med. 2019;17(31):1-13.
75. Kumanyika SK. A framework for increasing equity impact in obesity
prevention. Am J Public Health. 2019;109(10):1350-1357.
76. McLaren L. Socioeconomic status and obesity. Epidemiol Rev. 2007;
29(1):29-48.
77. Skouteris H, Bergmeier HJ, Berns SD, et al. Reframing the early child-
hood obesity prevention narrative through an equitable nurturing
approach. Matern Child Nutr. 2021;17(1):e13094.
78. Hatzenbuehler ML, Phelan JC, Link BG. Stigma as a fundamental
cause of population health inequalities. Am J Public Health. 2013;103
(5):813-821.
79. Ndumbe-Eyoh S. What would it take for health promotion to take
structural racism seriously? Global Health Promot. 2020;27(4):3-5.
80. Obesity Collective. Response to national obesity strategy consulta-
tion, December 2019. Accessed February 25, 2021. Available at
https://www.obesityaustralia.org/points-of-view/#statements
SUPPORTING INF ORMATION
Additional supporting information may be found online in the
Supporting Information section at the end of this article.
How to cite this article: Hill B, Bergmeier H, Incollingo
Rodriguez AC, et al. Weight stigma and obesity-related
policies: A systematic review of the state of the literature.
Obesity Reviews. 2021;22(11):e13333. https://doi.org/10.
1111/obr.13333