A Narrative Review and a Novel Stigma-Sensitive Approach to Study Weight Stigma Among Children

Introduction

Weight stigma refers to the negative or discriminatory acts, attitudes, beliefs and ideologies targeted towards individuals because of their weight and size (Puhl & Latner, 2007). Weight stigma has been studied in children, and research has shown that, in addition to adults, children also hold negative attitudes and perceptions toward overweight and obesity (e.g. Pasquale & Celsi, 2017; Puhl & Latner, 2007). As early as the 1960s, children were found to have negative attitudes toward individuals with overweight or obesity (Richardson et al., 1961), and it has been identified in children as young as age two (Su & Di Santo, 2012). Weight stigma with children is typically manifested as teasing, physical bullying and relational victimization (Puhl & Latner, 2007).

High prevalence of experienced weight stigma is alarming (Puhl & Lessard, 2020), given its numerous adverse psychological, social and physical health consequences. These include depression, anxiety, substance use, low self-esteem, self-harm behaviors, social isolation, adverse academic outcomes, unhealthy eating behaviors, decreased physical activity and exacerbation of obesity (e.g. Pont et al., 2017). The weight-amplifying effect of obesity stigma is based on the so-called negative feedback loop between weight and stigma, in which the psychological harm caused by weight stigma leads to behaviors that promote weight gain (Haqq et al., 2021). In addition, in a systematic review and meta-analysis by Ma et al. (2021), findings supported positive concurrent and bidirectional relationships between weight stigma and weight status among children and adolescents.

Childhood obesity has risen globally, prompting increased attention towards understanding the stigma associated with it. Evidence suggests that weight-related stigma among children has increased between 1961 and 2001 (Latner & Stunkard, 2003). Various studies report that between 24% and 96% of children with overweight or obesity issues have experienced teasing related to their body size or weight (Puhl & Latner, 2007). Children are particularly vulnerable to the negative consequences of weight stigma and weight-based teasing as the formation of social relationships plays a critical role in their developmental processes (Puhl & Latner, 2007). In this article, a stigma-sensitive approach refers to the consideration of negative social stereotypes and misconceptions associated with higher body weight throughout the research design, implementation, and reporting. The understanding that weight is often linked to undesirable personal characteristics (Puhl & Latner, 2007) served as a conceptual framework for the study. These known attitudes were particularly considered when developing the story for children, ensuring that stigma related ideas were not unintentionally conveyed or imposed through the choices presented.

The aim of this study is two-phased. Firstly, with a narrative review we wanted to explore, what kind of methods are used when studying weight-stigma perceptions among 2–12-year-old children and their main findings. Secondly, we studied weight-stigma-related thinking in Finnish children by conducting a study with a stigma-sensitive approach that addresses the ethical challenges of previous approaches. The goal is to stimulate wider discussion on the appropriate and effective methods for investigating weight stigma in children.

Narrative Review

The literature search was conducted in the PsycInfo and Scopus databases first in June 2023 and repeated in June 2024 by the first author. The search terms and query were formulated using words related to childhood and weight stigma (Supplemental Material 1). Since the review focuses on the manifestation of weight stigma in children, particularly on attitudes toward overweight and obesity in children, the search query included words related to children and weight stigma, weight bias, anti-fat attitude, weight-related stereotypes and weight-related discrimination. For the same reason the search query excluded topics related to parents, family, and internalized weight stigma. The search results were limited to peer-reviewed academic publications published in the 2000s. The inclusion and exclusion criteria for publications included on the literature review can be found in Supplemental Material 1.

The suitability of publications identified through database searches was first assessed based on the title and abstract, followed by a full-text evaluation. The results from different databases varied somewhat, but there were also overlaps. A total of 148 records were retrieved from the two database searches, of which 81 were selected based on the title and abstract. After full-text assessment, 27 publications were included. Additionally, four publications were identified through manual search and included in the review. After removing duplicates, a total of 23 publications were included in the review (Supplemental Material 2). We aimed to provide a descriptive synthesis of the findings of the included publications without statistical aggregation by using narrative synthesis. A narrative review approach (Gregory & Denniss, 2018) was adopted, as the included publications comprised both qualitative and quantitative methodologies and the primary focus of the review was conceptual.

Findings From the Narrative Review

Weight stigma in children has been studied using various methods, yet the findings appear to be consistent regardless of the methods used. Most of the studies included in this review have observed weight-stigma-related thinking in children. Children tend to have negative attitudes toward peers with overweight or obesity issues and prefer less social interaction with them.

However, research on children’s weight stigma has predominantly relied on quantitative methodologies, often involving tasks where children are asked to rate figures or photographs of peers with varying body sizes and physical features (e.g. Harrison et al., 2016). In these studies, researchers commonly ask children to rank figures based on preference or to associate descriptive adjectives with them, under the assumption that such tasks elicit attitudes and unconscious biases related to weight (e.g. Harriger & Trammell, 2022). Additionally, some research has focused on children’s social behaviors, particularly in friendship selection and interactions with peers of different body sizes, and how such social dynamics relate to weight (e.g. Harriger & Trammell, 2022; Harrison et al., 2016).

In studies that have quantitatively examined children’s weight stigma through their attitudes, children have been found to hold negative attitudes toward images or drawings of individuals with overweight or obesity issues (Kihm, 2014; Latner & Stunkard, 2003). Furthermore, in all studies included in this review that utilized predefined adjectives or statements, children associate more negative attributes and fewer positive attributes with characters or images depicting individuals with overweight or obesity issues (Harriger & Trammell, 2022; Harrison et al., 2016; Parnell et al., 2021; Su & Di Santo, 2012).

In addition to examining children’s attitudes toward obesity, research has also explored how these attitudes impact their social relationships. In two studies, school-aged children were asked to name their most and least preferred classmates, and these nominations were compared to the children’s body mass index (BMI) (De La Haye et al., 2017; Kornilaki & Cheng, 2019). De La Haye et al. (2017) found that children with overweight were less likely to be nominated as friends and more likely to be considered undesirable compared to children without overweight.

Similarly, Kornilaki and Cheng (2019) observed a relationship between body size and popularity: a lower BMI was associated with higher popularity, whereas a higher BMI was linked to a lower social standing. The studies also revealed that children are more likely to choose a medium- or small-sized character or peer as a friend rather than a character or peer with overweight or obesity (Harriger & Trammell, 2022; Harrison et al., 2016). Additionally, children are more likely to engage in various social situations or activities with a medium- or small-sized character or peer than with one who has overweight or obesity (Parnell et al., 2021).

In studies investigating gender differences in children’s weight stigma, a variety of methods have been used to examine the phenomenon, making the results not always comparable. In several studies, children have evaluated characters that match their own gender. In some of these studies, weight stigma was equally strong in boys and girls (Parnell et al., 2021; Skinner et al., 2017), while in others, it was observed that girls exhibit stronger weight stigma than boys (Harriger & Trammell, 2022; Latner & Stunkard, 2003). However, in contrast to other studies, Fitzgerald et al. (2013) found that boys exhibited stronger weight stigma than girls. As all children in their study, including boys, evaluated only female characters, this may have influenced the result. Gender is an important social factor for children, so they tend to prefer members of their own gender. For example, in a study by Charsley et al. (2018), children were more reluctant to befriend an opposite-gender character than one with obesity.

The research evidence regarding the impact of age on the intensity of weight stigma is conflicting. In some studies, examining 3- to 6-year-olds, it has been found that weight stigma is stronger in older children (Harriger & Trammell, 2022; Harrison et al., 2016; Rodgers et al., 2019). On the other hand, a study involving 4- to 11-year-olds has shown that weight-stigma-related thinking is stronger in younger children (Carvalho et al., 2021). Interestingly, Kihm (2014) found that weight stigma is stronger among 3rd, 4th, and 6th graders (around 8–9 and 11 years old) than among kindergarten, 1st, 2nd, 5th, 7th, and 8th graders (around 5–7, 10, and 12–13 years old). There is also evidence suggesting that a child’s age does not influence the intensity of weight stigma, as no differences were found between children aged 4–8 and those aged 9–11 (Skinner et al., 2017).

A few studies investigating children’s weight-stigma-related thinking have focused on children’s perceptions of the causes of obesity. Rodgers et al. (2019) examined children’s views on the growth of body size and the factors behind it by combining qualitative and quantitative methods. In interviews, children primarily attributed the growth of a character’s body size to factors related to the amount and quality of food, with only a small number of children citing a lack of physical activity as a reason. A small portion of children suggested that growing older, pregnancy, or magic were causes of body size growth. A significant portion of children viewed body size growth and weight gain negatively, offering negative comments.

Other studies have found that when children perceive body size growth and weight gain as being dependent on an individual’s behavior, such as eating habits, weight stigma is more likely to emerge (Carvalho et al., 2021; Fitzgerald et al., 2013). In these studies, children were shown a medium-sized character and a character with overweight and were provided an explanation for the character’s body size growth and weight gain. When weight gain was explained by biological factors, children expressed more positive attitudes toward the larger character. However, when weight gain was explained by individual behavior, children’s attitudes toward character were more negative (Carvalho et al., 2021; Fitzgerald et al., 2013).

Charsley et al. (2018) did not observe overt weight stigma in their qualitative research. When children were interviewed about the differences between the presented characters, they focused more on gender or visible disabilities than on weight. The findings of Pugmire and Lyons (2018) also partially contradict other research evidence. Using qualitative methods, they explored how children talk about health and obesity. Children perceived obesity as the opposite of good health and physical fitness, associating it with poor diet and excessive eating, while thinness was linked to good health. They viewed healthiness and body size as matters of personal choice. However, children also found an overly simplistic approach to health and obesity problematic and occasionally highlighted perspectives related to enjoyment, practicality, moderation, happiness, and well-being.

Overall, the findings of the narrative review indicate that research on weight stigma among children predominantly relies on quantitative methodologies. However, the methods used should be critically examined, particularly concerning their ethicality and reliability. Several studies employed methodologies that required children to make forced choices between limited or binary options. Such approaches may inadvertently reinforce, or even instill, weight-stigma-related thinking by constraining children’s responses and framing body-related judgments in a reductive manner.

Stigma-Sensitive Approach

After the findings from the narrative review, we conducted a study with a stigma-sensitive approach, which aimed to consider the results highlighted by the narrative review, particularly regarding the ethics and reliability of the research methods. The present study employed a qualitative child research approach, using a drawing task and an individual interview with stimulus material that included a read-aloud story. The research interviews were conducted in January 2024. The study design was reviewed and approved by the Committee on Research Ethics of University of Eastern Finland (Statement 46/2023).

Materials

As part of the study protocol, the researchers created a short fictional story (Supplemental Material 3) and an interview guide (Table 1). The story featured two characters, Pami and Tini, who go on a fishing trip. The names were selected as imaginary gender-neutral Finnish names. Three common stereotypes, identified in previous studies demonstrating that children hold negative perceptions of individuals with obesity, were applied to one of the characters, Tini: lazy, unhappy, and low self-confidence (Hansson et al., 2009; Tiggemann & Anesbury, 2000; Tiggemann & Wilson-Barrett, 1998). To emphasize the contrast between the characters, the other character, Pami, was portrayed with attributes opposite to those assigned to Tini: diligent, joyful and high self-confidence. These contrasting traits were conveyed through the characters’ actions. The gender and physical appearance of the characters were deliberately left unspecified to emphasize stigma-sensitivity of the study. The first author developed the story and created notes, from which a narrative text was produced with the help of AI (ChatGPT). Then the researchers revised and finalized the story. The interview guide was structured to include primarily open-ended questions, ensuring that children were not conditioned to consider weight stigma. The research questions guided the topics addressed during the interviews. The researcher piloted the study protocol with an 8-year-old child before the actual interviews.

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Table 1.

Interview Guide

The questions are repeated for both characters (Tini and Pami) in the story.

Other issues that arise may also be discussed with the interviewee.

1. Tell me what you have drawn.

2. What does Tini/Pami look like?

3. Why does Tini/Pami look like this?

• If necessary, specify different body parts, e.g. head, hair, face, arms, torso, legs, other features.

4. How do the characters differ from each other?

5. What kind of personality does Tini/Pami have?

6. How do the characters’ personalities differ?

7. What is the general nature of the children who resemble Tini/Pami (referring to the drawings)?

8. Is there anything else you would like to tell us about Tini/Pami?

9. Any questions you want to ask?

Finally, summarize what was discussed.

Tell the child that if they have any questions afterwards, mum or dad will have my contact details.

Results

Categories Identified

Based on the children’s interviews, the analysis revealed that children predominantly focused on the events of the story, as well as the personalities and emotions of the characters, rather than their physical appearances. When the children were specifically asked about the characters’ appearances, their descriptions primarily revolved around clothing and color. The categories that were formulated based on children’s stories were personality, emotions, appearance, gender, events and activity, and body shape and size. Table 2 provides a more detailed overview of the identified categories, accompanied by illustrative quotes from the children’s interviews.

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Table 2.

Categories Related to How Children Interpreted the Story Characters and Number of Children Mentioning the Attributes (n=15, Range 0−15)

Categories (n)	Sample quote excerpts (C=child)	Observations
Personality
Lazy (6)	C6: She wanted to stay in bed; C11: Tini is a little bit lazy; C12: Tini wants to just sit down and eat candy	Based on a story, children described Pami with verbs related to activity and Tini related to laziness.
Brisk (7)	C5: Tini likes to do everything; C7: She is excited in many things, and she wants to be crazy and fun; C10: Pami is brisk
Funny (2)	C7: Pami’s face looks excited and fun; C10: Pami looks like fun
Kind (4)	C4: Tini behaves well; C6: Pami is, like, a kind child
Trusting (1)	C7: Tini is kind, brave and trusting
Active (5)	C1: This one takes the fishing rod first; C12: Pami looks like they want to play football and all different games; C7: She moves a lot, so she doesn’t want to wear shoes
Emotions
Happy (10)	C2: She looks at the fish, and she has a smiling mouth; C3: Her face looks happy; C6: Pami looks like that because he is happy to go fishing	Children described the characters’ emotional states, Pami frequently associated with feelings of happiness and excitement, whereas Tini was mostly described as tired.
Excited (4)	C2: I think they would be like ‘hooray we got three fish!’; C4: Tini looks excited; C8: Pami is really excited to go fishing
Tired (4)	C1: They probably wanted to sleep more; C6: Tini looks a little bit tired
Perky (2)	C7: Tini looks perky and happy at the same time; C12: Pami’s face seems perky and happy
Not in the mood (5)	C4: Pami doesn’t want to take the fishing rod; C8: Tini is like ‘I don’t want to go fishing’
Appearance
Clothes and hair (12)	C2: Tini has a turquoise dress and hair and there’s a red heart on the dress; C3: Pami has a long shirt and pants and shoes; C7: The hair is like… They have a ponytail	When discussing the characters’ physical appearances, children primarily focused on their clothing, hair, and the colors associated with them.
Looks ordinary (7)	C1: Tini’s face looks quite ordinary; C4: Pami’s body looks ordinary; C6: His hands and feet look normal	Most other children only provided descriptions of the characters’ appearances after being explicitly prompted by the researcher.
Looks good (2)	C2: Pami looks good; C14: Tini’s face looks good	​
Gender (5)	C3: She’s a girl, so I figured pink gloves suit her; C3: He has long hair even though he is a boy; C6: The other one looks like a boy and the other one looks like a girl	Only five out of the fifteen children explicitly stated that the characters were male or female, while the remaining children did not mention gender
Events and activity (11)	C3: Over here the seagull says ‘berries’; C9: I drew two cats, who are sitting at the fishing spot; C13: Here they are coming home from the fishing trip, and they have fish	The children showed a marked interest in the events of the story, with half of them depicting the characters engaged in activities described in the narrative (e.g., fishing). When the researcher inquired about their drawings, most children discussed the events they had illustrated.
Body shape and size
Height (6)	C1: His arms look quite short, but his legs are a bit longer; C5: Tini’s legs look long and durable; C10: Pami is a little bit smaller, a bit shorter	The children paid significantly less attention to the characters’ body size compared to other aspects such as personality, emotions, clothing, hair, colors, or activities

Children’s Perceptions of the Story Character’s Bodies and Weight Bias

None of the children spontaneously mentioned body size when asked to describe their drawings. However, when explicitly questioned about the characters’ appearance, eight out of fifteen children commented on the body size, focusing primarily on the characters’ height. Although some children described one character as “big” or “small”, upon further inquiry, they clarified that they were referring to height rather than overall body size:

Child 11: “Tini is a little bit bigger than Pami.”

Researcher: “In what way?”

Child 11: “Well, Tini is a bit taller.”

Some children differentiated the characters based on height (Figure 1

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Figure 1.

Drawing made by child 11 (age 8). The character Tini on the right is portrayed taller, and Pami on the left is portrayed shorter

), but no consistent pattern of associating height with a specific character emerged across the interviews.

Importantly, no explicit weight bias was observed in the children’s responses. None of the children associated larger body sizes or obesity with either character, and the topic of obesity did not arise in either the drawings or the interviews (Figure 2). Four children mentioned “chubbiness”, illness, candy consumption (character Tini), and an athletic appearance (character Pami) when discussing the characters’ physical traits. Child 5 described that “Pami’s body looks, like, ordinary. They look like they don’t have any illness or such.” and Child 14 that “Pami’s body doesn’t look chubby, it’s just right.”

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Figure 2.

Drawing made by child 14 (age 8). The character Tini is on the right and Pami on the left. The characters appear to have similar physical characteristics, and they are differentiated through different colored clothing

Discussion

The first aim of this study was to explore with a narrative review, what kind of methods are used when studying weight-stigma perceptions among 2–12-year-old children and what results these studies have gained. Most of the studies reviewed used quantitative research methods. These methods have advantages such as repeatability, ease of use, and cost-effectiveness, especially when dealing with large sample sizes. However, when studying children’s weight stigma as a phenomenon, the quantitative methods used, such as associating adjectives with cartoon characters, may seem too simplistic and detached from reality. For example, Harriger and Trammell (2022) found in their study that children had negative attitudes toward cartoon characters depicted as overweight, but weight stigma and discrimination were not observed when children were asked to choose a character as a friend. Thus, children’s negative attitudes may not necessarily manifest in behavior.

There has been relatively little research on children’s weight stigma using qualitative methods, but such methods have provided valuable and deeper insights into children’s thoughts and attitudes (Charsley et al., 2018; Pugmire & Lyons, 2018). Using qualitative methods, it has been observed that children do exhibit weight stigma, but it is not as obvious or straightforward as the results obtained with quantitative methods might suggest. More research is needed on children’s weight stigma, particularly using qualitative methods, to better understand the phenomenon and the factors behind it. Qualitative research holds an important place in the study of health-related phenomena, such as obesity (Barbour et al., 2007), and this type of research should also be increased in the context of weight stigma. Qualitative approaches hold promises for capturing a more nuanced, child-centered understanding of weight stigma. Techniques such as interviews and observational methods allow for a deeper exploration of the multidimensional and context-dependent nature of the stigma (Charsley et al., 2018).

In addition to considering the different methodological aspects between qualitative and quantitative research, more attention should be given to developing stigma-sensitive research methods for examining weight stigma among children. By asking children to compare and differentiate between figures of varying body types, these methodologies may inadvertently suggest to children that these differences are significant, thus potentially reinforcing or even generating weight-related biases. Quantitative methods, such as adjective association tasks with child figures, may also oversimplify the complex nature of children’s perceptions. Quantitative methods often employ forced-choice paradigms, requiring children to rank characters (Kihm, 2014; Latner & Stunkard, 2003) or assign specific attributes (e.g. Harriger & Trammell, 2022; Parnell et al., 2021), even if the distinctions between characters are not meaningful to the child. This can produce distorted results. For example, a child might view two characters as equally likable, but forced-choice methods compel a preference, leading to conclusions that may not accurately reflect the child’s true perceptions. Furthermore, a child may feel that none of the adjectives apply to the figures presented, yet the forced-choice design requires a selection, thereby distorting the results. This methodological limitation may lead to an overestimation of the prevalence and strength of negative attitudes toward overweight or obese peers (Jarvie et al., 1983). Despite these limitations, the body of research using forced-choice methods provides robust evidence of the existence of weight stigma in children (Puhl & Latner, 2007), contributing valuable insights into the phenomenon’s prevalence and social manifestations.

The second aim of this study was to test weight-stigma-related thinking in Finnish children by conducting a stigma-sensitive approach that addresses the challenges of previous approaches. Therefore, an approach which aimed to consider the results highlighted by the narrative review was planned, particularly regarding the ethics and reliability of the research methods. The present study employed a qualitative child research approach, using a drawing task and an individual interview with stimulus material that included a read-aloud story. There has been previous research, where these kinds of approaches have been used when exploring children and sensitive issues like childhood obesity. For example, Meriaux et al. (2010), used drawings and body pictograms to supplement the interviews.

The findings of this study suggest that children, when listening to a story in which no explicit comments about physical appearance are made, focus more on the events of the story, as well as the characters’ personalities and emotions, rather than their physical appearances. These findings diverge from previous research. A substantial body of evidence indicates that weight bias is prevalent among children, with negative attitudes towards individuals with larger body sizes being common (Puhl & Latner, 2007; Puhl & Lessard, 2020). Earlier studies have shown that children tend to hold negative attitudes toward peers with overweight or obesity (e.g. Harrison et al., 2016; Latner & Stunkard, 2003) and are less likely to engage in friendship behaviors with children who are overweight or obese (e.g. De La Haye et al., 2017; Harriger & Trammell, 2022). However, much of this research has relied on quantitative methods. In contrast, as with the current study, two previous qualitative studies found no evidence of apparent weight stigma in children (Charsley et al., 2018; Pugmire & Lyons, 2018). These findings suggest that the choice of methodological approach may influence our understanding of the phenomenon and the identification of children’s own perspectives.

In two studies (Carvalho et al., 2021; Fitzgerald et al., 2013), it was interestingly observed that children’s weight stigma was less pronounced when they were told that the growth of body size was due to biological factors. On the other hand, weight stigma was more pronounced when it was explained that the growth of body size was due to the individual’s own behavior. When considering individual behavior and obesity, there is previous research that children tend to combine obesity with individual choices in eating and exercise (Pugmire & Lyons, 2018; Rodgers et al., 2019). Therefore, the emergence of weight stigma in children could be influenced by upbringing and education: the growth of body size and weight gain has many different underlying factors, and the mechanisms that affect an individual’s weight are complex.

Based on the literature review, weight stigma among children is common, and the results of studies on the topic are largely consistent with each other, despite the different research methods used. Studies have shown that children have negative attitudes toward other children with overweight or obesity, and they are less likely to engage socially with them compared to children with no overweight. However, the methods where children are asked to compare different-sized and shaped characters or images of children raise the question of whether these methods reinforce the weight stigma observed in children. Children may not make similar comparisons in their everyday lives, and the research method could guide children to think that the differences between the presented characters or children are somehow significant. Therefore, the method could reinforce or even cause weight-stigma-related thinking. By using forced choice, the child may be hesitant to give a response that is not socially acceptable. Forced choice, therefore, brings the phenomenon to the surface easily, but it may not accurately reflect reality.

To our knowledge, only one previous study has employed a methodology comparable to that of the present research (Leddy, 2011). In Leddy’s study, children aged 3 to 4 were presented with a story featuring a “mean” and a “nice” character, after which they were asked to draw the characters and participate in interviews. Of the twenty-three children in that study, only two depicted the “mean” character with a larger body size than the “nice” character, indicating a minimal presence of weight bias. Similarly, no evidence of weight bias emerged in the current study. Despite similar findings, variations in study design—such as sample size, participant age, and story characteristics—should be considered.

None of the children in this study imagined a character that was noticeably overweight or obese. This finding prompts consideration of the types of characters children tend to draw. Research suggests that children are more inclined to illustrate characters with positive facial expressions and emotions, favoring pleasant and socially acceptable depictions over those that may be perceived as negative or undesirable (Cannoni et al., 2023). The absence of overweight or obese figures in the children’s drawings may therefore reflect also an implicit bias where larger body sizes are not viewed as desirable or “pleasant” characteristics.

Supplemental Material

Supplemental Material

Supplemental Material

Supplemental Material