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MINIREVIEW Type 2 diabetes in youth1 Biochem. Cell Biol. Downloaded from www.nrcresearchpress.com by STOCKHOLMS UNIVERSITET on 11/22/15 For personal use only.

Erin Cameron and Caitlin O'Reilly

Abstract: Since the 1990s, concerns about a global obesity epidemic have flourished. These concerns regarding obesity are expressed in popular culture and scientific literature and emphasize both weight and weight loss when defining health and well-being. As a result scholars are now calling attention to a “shadow epidemic” of weight stigma that is shown to have harmful physiological and psychological impacts in youth. In tandem with “globesity” concerns, there has been a similar concern expressed over the epidemic of type 2 diabetes, which some have termed “diabesity.” Although there is less known about diabetes stigma, the topic has much overlap with obesity stigma. In this narrative review we discuss the related problems of obesity and type 2 diabetes stigma, with an emphasis on issues specific to youth, as relevant. Drawing from literature on weight bias, critical weight studies, and Health at Every Size (HAES), we highlight pedagogical approaches to address obesity stigma and their implications to redress the problem of type 2 diabetes-related stigma in health care. Key words: weight stigma, diabetes stigma, obesity, pedagogy, health care. Résumé : Depuis les années 1990, les inquiétudes que soulève l'épidémie mondiale d'obésité ont augmenté. Ces inquiétudes face a` l'obésité s'expriment dans la culture populaire et dans la littérature scientifique, et mettent l'emphase sur le poids et la perte de poids lorsque vient le temps de définir la santé et le bien-être. Par conséquent, les chercheurs veulent attirer l'attention sur une « épidémie souterraine » de stigmatisation en lien avec le poids, que l'on sait avoir des impacts physiologiques et psychologiques négatifs chez les jeunes. De pair avec les inquiétudes face a` la « globésité », une inquiétude similaire s'est manifestée face a` l'épidémie de diabète de type 2, que certains ont appelé « diabésité ». Même si l'on en connaît moins sur la stigmatisation du diabète, le thème chevauche de manière importante la stigmatisation de l'obésité. Dans cette revue narrative, les auteurs discutent des problèmes liés de la stigmatisation de l'obésité et du diabète de type 2, en mettant l'emphase sur les conséquences spécifiques importantes pour les jeunes. Extrayant des données de la littérature sur les préjugés envers les obèses, les études sur le poids critique et le mouvement Health at every size (HAES), les auteurs mettent en lumière les approches pédagogiques pour répondre a` la stigmatisation de l'obésité et leurs implications pour résoudre le problème de la stigmatisation liée au diabète de type 2 dans le milieu de la santé. [Traduit par la Rédaction] Mots-clés : stigmatisation du poids, stigmatisation du diabète, obésité, pédagogie, milieu de la santé.

Introduction Since the 1990s there has been growing international concern expressed in both the media and weight science literature over increasing rates of overweight and obesity and their health and economic implications. While this weight-focused approach to health — in which both weight and weight loss are used to define health and wellbeing — remains dominant, a growing number of scientists are challenging this approach, given the evidence of its adverse physiological and psychological effects on patients (Tylka et al. 2014) and its failure to recognize the social determinants of health (Raphael 2009). These scholars, among others, have also illustrated how such an approach and current obesity prevention strategies are contributing to what has been coined a “shadow epidemic” (Daghofer 2013) of weight stigma. As obesity concerns have escalated over the last two decades, so too have rates of obesity stigma (Andreyeva et al. 2008; Latner et al. 2008). Concerned with this trend, organizations like the Canadian Obesity Network-Réseau Canadien l'Obesité (CON-RCO) are now making weight bias a priority area in obesity management (CON-RCO 2011). In the last two decades an extensive amount of research has explored and documented the prevalence and consequences of weight stigma (see Brownell et al. 2005; Puhl and Heuer 2009),

referring to the devaluing of body sizes that are perceived to be higher than “normal” within society (Puhl and Brownell 2006). Weight stigma is now cited as a concern across society, including in employment, education, interpersonal relationships, the media, and notably in health care (Puhl and Heuer 2009). The literature suggests that perceived weight stigma may result in poor self-esteem, depression, body image disturbances, lowered physical activity, emotional eating, disordered eating, avoidance of health care, and challenges in school (Puhl and Heuer 2009). More recently, scholars have focused on exploring the negative consequences of weight stigma in youth, now shown to be one of the most salient forms of bullying within school environments (Puhl and Brownell 2001; Puhl and Latner 2007). Researchers concerned with weight stigma agree that interventions are urgently needed to redress this issue. To this end, several strategies for mitigating weight stigma have been proposed and tested, as discussed later. In tandem with growing international concern over rates and consequences of overweight and obesity, there has been a similar worry expressed over the epidemic of type 2 diabetes. Although less is known about type 2 diabetes-related stigma, the topic has much overlap with obesity stigma, and the growing body of literature suggests that those living with type 2 diabetes feel stigmatized and as a result are experiencing adverse physiological and psychological effects (Browne et al. 2013; Kalra and Baruah 2015;

Received 29 September 2014. Revision received 17 January 2015. Accepted 2 February 2015. E. Cameron. Memorial University, Physical Education Building, St. John's, NL A1C 5S7, Canada. C. O'Reilly. School of Kinesiology, University of British Columbia, 210-6081 University Boulevard, Vancouver, BC V6T 1Z1, Canada. Corresponding author: Erin Cameron (e-mail: [email protected]). 1This article is part of Special Issue entitled Type 2 Diabetes and has undergone the Journal's usual peer review process. Biochem. Cell Biol. 93: 430–437 (2015) dx.doi.org/10.1139/bcb-2014-0133

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Nicolucci et al. 2013; Kalra et al. 2009). In this narrative review we discuss the related problems of obesity and type 2 diabetes stigma, with an emphasis on issues specific to youth. Drawing from literature on weight bias, critical weight studies, and Health at Every Size (HAES), we highlight effective pedagogical approaches to address obesity stigma and their implications to mitigate the problem of type 2 diabetes-related stigma in health care.

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Methods Narrative reviews are comprehensive syntheses of previously published information that help to provoke thought and interest in a specific field of research. They are particularly useful in covering broad topic areas, while providing relevant historical context and offering educational perspectives that help to inform clinical practice (Green et al. 2006). For this review, a search of education and health care focused electronic databases was conducted (i.e., ERIC; Proquest; EBSCO; Academic Search Premier; JSTOR; MEDLINE; PubMed) using keywords that included but was not limited to the following: type 2 diabetes, obesity, fat, bias, stigma, oppression, discrimination, bullying, and education. Journal articles and grey literature were also included in this search (e.g., government documents, conference proceedings, organization websites, etc.). Articles were considered if they addressed either type 2 diabetes stigma or obesity stigma, and if they included pedagogical approaches and strategies that focused on reducing stigma or disrupting dominant discourses.

Discussion Understanding stigma Since the seminal work of Goffman (1963), research on stigma has been popular in the social science literature. Goffman (1963) conceptualized stigma as an attribute that is socially discrediting. He emphasized that attributes themselves are not inherently stigmatizing, but rather it is the meaning assigned to certain attributes through interaction and relationship that allows for stigma. A decade before Goffman, Allport (1954) brought the notion of prejudice into the purview of social science. Allport (1954) conceptualized prejudice as a cognitive pre-judgment, that when paired with antipathy towards a group or person leads to prejudice (Dovidio et al. 2005). Although these two topics initially were studied as separate phenomena, today the terms are often used interchangeably in the literature. At other times, prejudice is conceptualized as an attitudinal manifestation of a broader stigma process (Phelan et al. 2008). In the decades since Goffman (1963) and Allport (1954), research on stigma and prejudice has grown and evolved. Much research on the topic, particularly prior to the new millennium, focused on the problem of stigmatizing attitudes about devalued attributes and was primarily undertaken by social psychologists (Link and Phelan 2001). Two prominent theories in this regard are attribution theory and social consensus/norms theory. Attribution theory is a psychosocial theory of prejudice that suggests that in societies where individualism is highly valued, when a person deviates significantly from normative expectations and that difference is attributed to their individual choices, stigmatizing attitudes will result (Puhl and Brownell 2003). Social norm or social consensus theory suggests that biased attitudes are influenced by group norms, especially the norms and attitudes of socially influential people (Puhl et al. 2005). Since the new millennium there has been an increased emphasis in the stigma literature on macro-level factors that enable stigma (Yang et al. 2007), such as the centrality of labels and power to the stigma process. Link and Phelan (2001) argued that it is from labels that other components of stigma, such as stereotypical attitudes and discrimination result. Link and Phelan (2001) and Link et al. (2004) emphasized that labels are different than the concept of attributes, as labels leave room to consider the social construc-

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tion of the characteristic considered deviant and different. This is important, they argue, because if we look across time and place we can see that the same attributes that are viewed negatively in one context are socially valued in another. Thus, no one attribute is itself inherently stigmatizing. Rather, it is through a social process of labeling and stereotyping that some attributes come to be viewed negatively. Link and Phelan (2001) further contended that it is crucial to understand that stigma is connected to ideas of power: it takes power to stigmatize and to label some people — but not others — as lesser in some way. Weight-related stigma Relative to the broader stigma and prejudice fields, the study of weight stigma is in its infancy (Daníelsdóttir et al. 2010). Scholarship on weight stigma and bias took a strong foothold in the literature in the 1990s (Brownell et al. 2005). Since then research on the topic has exponentially increased, as have our understandings of the problem. Today a large body of literature exists exploring the prevalence and consequences of the issue. Body size serves as yet another axis of signification used to stigmatize, often in similar ways to better known types of discrimination, such as sexism, racism, classism, and ableism (Lupton 2013). Positive correlations between exposure to weight bias and greater cortisol reactivity, known as a biological marker of chronic stress, is just the latest in the growing body of literature documenting the negative effects of weight stigma (Schvey et al. 2011). Weight bias exists in diverse settings, including within health care. Physicians (Huizinga et al. 2009; Monaghan 2010; Warner et al. 2008), nurses (Camden 2009; Creel and Tillman 2011) and dietitians (Puhl et al. 2009) have shown to be specifically susceptible to weight stigma. Not only does this influence the level of care patients receive (Huizinga et al. 2009), but since weight bias is known to cause direct and indirect stress, there is the chance that these health care professionals are unintentionally causing further harm to their patients (Kirk and Penney 2010). For instance, some of the known consequences of weight bias are vulnerability to depression, low self-esteem, poor body image, maladaptive eating behaviours, and exercise avoidance (Puhl and Heuer 2009). To date, weight stigma literature has suggested that the prevalence of weight bias may actually be increasing in settings such as health care, and that stigma-reduction strategies remain an important key area of future research. Weight stigma has shown to be particularly salient in youth and impacts children as young as three years of age (Harriger et al. 2010). Weight bias is one of the most common forms of bullying in schools (Puhl and Brownell 2001; Puhl and Latner 2007). In a recent study examining the frequency of weight-based bullying, Puhl et al. (2011) found that 92% of the students witnessed weightbased victimization, and 75% of the students reported experiencing weight-based victimization. Weight status is not only said to be the “number one reason for peer rejection in America” (Jalongo 1999 p. 95), but longitudinal research has concluded that weight status significantly predicts future victimization, with the heaviest youth at risk (Griffiths et al. 2006). Weight-based bullying in youth is associated with negative social consequences, such as lower body image, higher depression, and higher suicide ideation (Eisenberg et al. 2003, 2006). It also has long-term health impacts causing weight gain, disordered eating, and binge eating up to five years post victimization (Neumark-Sztainer et al. 2007). Other consequences of concern are that victims of weight-based bullying are more likely to avoid going to school, report that their grades are affected, and to be involved in incidents leading to suspensions (Daniels 2008; Puhl and Luedicke 2011). Weight-based bullying is found to occur in lunchrooms, cafeterias, and classrooms (Puhl et al. 2011), but is found to occur most frequently during schoolbased physical activity and in physical education classes (Fox and Edmunds 2000). Within these settings, students have reported Published by NRC Research Press

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feeling discomfort and embarrassment, and have often been excluded from participating in some of the activities (Pierce and Wardle 1997; Trout and Graber 2009). One study found that weight-related bullying is a major barrier to participating and being fully engaged in physical education (Bauer et al 2004). Female youth seem to be particularly vulnerable given that normative body size ideals are more strictly and publicly enforced for girls (Wardle et al. 2002), fueling body dissatisfaction and concerns about appearance (Slater and Tiggemann 2011; Smolak 2004). Among those studying weight stigma, while there is a seeming consensus on the prevalence, gravity, and consequences of the issue, particularly for youth, there is less agreement on how to best conceptualize the topic. Thoroughly conceptualizing the issue is important to help us best consider what to do about the problem of obesity stigma. Conceptualizing weight stigma The most prominent source of information on weight stigma comes from within The Rudd Center for Food Policy and Obesity at Yale University. Researchers such as Rebecca Puhl, Kelly Brownell, and Marlene Schwartz have produced an unparalleled volume of literature on the scope and consequences of weight bias, conceptualizing weight stigma as a problem of societal attitudes that lead to negative outcomes for and behaviours towards overweight and obese people. From a theoretical perspective, these researchers suggest that weight stigma exists due to (largely incorrect) assumptions that weight is within an individual's control, as consistent with attribution theory (Puhl and Brownell 2003), assumptions that allow for a great deal of blame to be placed on overweight and obese people for their weight. They also advocate for social norms and consensus theory as an explanation for weight stigma (Puhl et al. 2005). In contrast to the attributional and social norm approaches to stigma advocated by the researchers at the Rudd Center and other social psychology approaches to weight stigma (Crandall 1994), scholars within the emerging field of fat studies articulate a relationship between the medicalization of weight and weight stigma. Wann (2009), controversially argues that “[o]verweight” is inherently anti-fat. It implies an extreme goal: instead of a bell curve distribution of human weights, it calls for a lone, towering, unlikely bar graph with everyone occupying the same (thin) weights. If a word like “overweight” is acceptable and even preferable, then weight stigma becomes accepted and preferred. (Wann 2009 p. xii)

Corroborating Wann's (2009) contentions, Saguy (2013) recently investigated the relationship between beliefs about fatness as a health problem and weight-biased attitudes. In a series of seven experiments, participants were presented with real news articles on weight and then asked attitudinal questions. Control groups were presented with non-problem framed articles (e.g., suggesting people of various weights can be healthy if they are eating well and being active), whereas the other groups were presented with various problem and blame-frame articles (e.g., fatness as a health problem or public health crisis). Saguy found that exposure to medical or public health frames made participants more likely to score as biased on attitudinal measures of anti-fat bias than those exposed to non-problem frames. McMichael (2013), following interviews with heavier individuals, similarly argued that thinking about fatness as a disease leads to weight stigmatizing attitudes and negative treatment of fat people. She contends that the harmful ideology of blame often overtly expressed towards overweight and obese people for their body size is only seen as socially acceptable because adiposity is thought of as a health problem. Relatedly, O'Reilly and Sixsmith (2012) contended that public health promotion of weight-centered approaches to health should

be considered a form of systemic discrimination, given that focusing on weight loss and energy deficits can lead to both eating disorders and weight cycling and associated health problems. These authors point to a study by Ernsberger and Koletsky (1995), who found that weight cycling may be worse for health than maintaining a high, yet stable, weight. O'Reilly and Sixsmith (2012) and Bacon and Aphramor (2011) also argue that the relationship between weight and health is not as clear as we are often led to believe. For instance, they point to research that demonstrates that people who are overweight live longer than those categorized as normal weight (Durazo-Arvizu et al. 1998; Flegal et al. 2005). They also suggest that many studies that find overweight and obesity to be harmful for health do not control for diet, fitness, socioeconomic status, or weight cycling. Campos et al. (2005) contend that when these variables are controlled for the relationship between weight and health becomes less clear. Although the idea that weight may not be causally related to health is contentious and hotly debated, a much less controversial idea is that weight as a primary measure of health may cause harm and stigma. As McVey et al. (2013) found, educating public health professionals about the harms of focusing on weight as a measure of health led to significant reductions in attitudinal measures of weight stigma. In this paper we take the position that regardless of the extent to which higher weights are or are not related to negative health outcomes, focusing on weight loss as a measure of health may result in stigma and associated consequences, including disordered eating and weight cycling (see Bacon and Aphramor 2011; O'Reilly and Sixsmith 2012). Type 2 diabetes stigma Type 2 diabetes stigma is a less often researched topic than obesity stigma but is a concept with much overlap and relationship to weight stigma. In a systematic review of diabetes-related stigma, Schabert et al. (2013) found that while type 1 and type 2 diabetes are not often considered stigmatized conditions, those with both type 1 and type 2 diabetes report significant stigmatization that influences both psychological and physiological wellbeing. Studies have found that people with diabetes (both type 1 and type 2) report feeling embarrassed, judged, and stigmatized when engaging in the essential self-care activities (i.e., monitoring blood glucose levels, injecting insulin, taking medications, eating healthily, and engaging in physical activity), and that diabetes stigma has had long-term negative impacts on social and employment opportunities. Consequences of such stigma include increased anxiety, depression, avoidance, and overall sub-optimal diabetes management. Schabert et al. (2013) suggest that this is driven by a culture of blame and shame that strictly enforces body norms, privileging thin, fit, strong, and able bodies, while marginalizing other bodies. In their article “Obesity stigma: a newly recognized barrier to comprehensive and effective type 2 diabetes management”, Teixeira and Budd (2010) write “[a] pervasive and ignored barrier to lifestyle modification interventions with T2DM patients are anti-fat social attitudes” (p. 527). They argue that while lifestyle modification is a key approach to prevent/delay the onset of diabetes and relevant complications, understanding and developing sensitivity towards diabetes stigma, and its relationship with obesity stigma, is of utmost importance. In addition to the above studies specifically on type 2 diabetesrelated stigma, the issue shares extensive overlap with obesity stigma. Many people with type 2 diabetes are also overweight or obese (Anderson et al. 2003), thus likely to experience similar challenges with weight bias as their metabolically healthier overweight or obese peers. Another similarity between the two concepts is around the ideology of blame. Both adiposity and type 2 diabetes are often seen as controllable via diet and exercise, thus people who are heavier and (or) suffer from type 2 diabetes may be exposed to blaming attitudes about their weight and stereotyped Published by NRC Research Press

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as lazy, lacking in will power, or noncompliant with health care recommendations. In the type 2 diabetes literature, weight loss is sometimes recognized as helping to improve health (Anderson et al 2003). However, as with overweight and obesity more generally speaking, focusing on weight as a measure of health among people with type 2 diabetes may result in unintended health consequences, including eating disorders and the health detriment associated with weight cycling. With youth in particular, experts in eating disorders have suggested that focusing on weight and weight loss could lead to unhealthy preoccupations with weight and shape and possibly to disordered eating or eating disorders (Larkin and Rice 2005; McVey et al. 2008; O'Dea 2005; Piran 2004). Given the vulnerabilities youth have to low self-esteem, body-dissatisfaction, and unhealthy behaviours, eating disorders have become increasingly problematic, with evidence suggesting one in four teen girls struggle with disordered eating (e.g., unhealthy dieting or eating behaviors; McVey et al. 2004). Dieting is problematic among youth for many reasons, one being the relationship between dieting and clinical eating disorders. Adolescents who diet “severely” are 18 times more likely to develop a clinical eating disorder, and those who diet “moderately” are five times more likely to develop an eating disorder (Flynn 2003). From a type 2 diabetes prevention perspective, dieting again may create unintentional consequences. Bossuyt et al. (2012) discuss the developmental origins hypothesis of type 2 diabetes. In their study they argue that undernutrition during early development (post-natal) is associated with an increased type 2 diabetes risk in adulthood. They base this finding on a sample of 7837 women from the European Prospective Investigation Into Cancer and Nutrition (Prospect-EPIC) study, who experienced dietary restriction during the 1944 to 1945 Dutch famine when they were between the age of 0 and 21 years. Those who experienced more extreme famine were at the greatest risk of developing type 2 diabetes, after controlling for other confounders. The authors acknowledge, however, that the study could not account for the extent to which this effect was the result of the dietary restriction or the psychological stress participants experienced during the famine. However, the issues of stress and extreme dietary restriction are likely intimately related. Other research has demonstrated that restrictive eating increases cortisol output, and that watching calories increases perceived stress (Tomiyama et al. 2010). This suggests that irrespective of whether dietary restriction itself or the associated stresses caused health detriment, that health care providers need to be aware that promoting dieting as a means of improving health may have unintended consequences. It is evident through the literature that type 2 diabetes stigma can trigger a maladaptive cycle of poor psychological and physiological health that can further compromise optimal diabetes management. However, there is a lack of evidence about how best to tackle type 2 diabetes stigma. To address this gap in the literature, we draw from the extant literature on weight-related stigma reduction in education and health care in an effort to better understand and offer ways forward for reducing type 2 diabetes stigma. Given the need for more research “to focus on how to dispel stigmatizing attitudes and practices, particularly in health care settings, and how to minimize the impact of diabetes-related stigma” (Browne et al. 2013 p. 9), we believe weight-related stigma reduction literature has much to offer diabetes-related stigma literature. Stigma reduction strategies in education and health care To date, most of the research on weight-related stigma reduction has been conducted within educational contexts, and very little has been conducted in the realm of health care. Numerous experimental and quasi-experimental studies have endeavoured to mitigate weight-biased attitudes within educational settings based on: consciousness raising/cognitive dissonance, attribution

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theory, and social consensus/norms (Daníelsdóttir et al. 2010). Results from such studies remain mixed. For example, a number of studies report reducing weight bias in students through education-focused interventions that provide information about the complexity and socio-cultural origins of obesity (such as Crandall 1994; Diedrichs and Barlow 2011; Puhl et al. 2005); other studies using similar strategies have shown no change in weightbiased attitudes (such as Bell and Morgan 2000; Harris et al. 1991). Studies that have used multi-intervention strategies also have shown mixed results. For example, in one 6 week intervention study with pre-service teachers that included lectures related to weight bias and a service learning project with school-aged children, students' negative beliefs about personal responsibility for obesity were reduced, but not their anti-fat prejudice (Rukavina et al. 2008). Given the success of empathy and reflective-based intervention strategies to reduce prejudice in other stigmatized groups, a number of studies have looked at interventions that promote empathy and acceptance (Puhl and Heuer 2009). While some studies examined the efficacy of short empathy-evoking videos in reducing weight bias (Hennings et al. 2007), others examined the use of first-person narratives (Batson et al. 1997; Gapinski et al. 2006; Teachman et al. 2003); such interventions had little to no impact on weight bias. Other empathy-based interventions include restricting calorie intake among health care students for a 1 week period to increase students' awareness of the challenges of losing weight (Cotugna and Mallick 2010), using web-based educational modules promoting size acceptance (Hague and White 2005) and exposing students to people above the “normal” weight (Wiese et al. 1992). The power of social influence — how emotions, opinions, and behaviours are affected by others in the classroom — has also been the focus of recent weight bias reduction interventions (Daníelsdóttir et al. 2010). A few studies have examined the role of social influence with regards to group consensus and social norms (see Stangor et al. 2001). For instance, Puhl et al. (2005) used phony feedback from influential peers about the attitudes and beliefs about fat people, which was shown to significantly impact students' attitudes towards fatness. While research on interventions to reduce weight bias remain limited, the methodological and scope-of-practice challenges within existing research remains a bigger issue. Daníelsdóttir et al. (2010) suggest that the research thus far has been plagued with methodological problems, including a lack of methodological rigour — such as a failure to include pre-test measurement — that limits the interpretability of results. Those studies that they deemed to have employed more rigorous experimental designs, with preand post-test measurement, have shown limited effectiveness. Daníelsdóttir et al. (2010) conclude, “given the strength of antipathy displayed toward those who are perceived as fat or obese, research in this area is urgently required” (p. 47). The importance of identifying effective methods for reducing weight stigma cannot be understated, particularly in education and health care. Beyond experimental studies, some scholars have provided anecdotal accounts of teaching experiences related to weight stigma (Boling 2011; Escalera 2009; Fisanick 2007; Guthman 2009; Tirosch 2006; Russell et al. 2013; Watkins and Doyle-Hugmeyer 2013; Watkins et al. 2012) and other scholars have ventured to provide pedagogical ideas for the classroom (Fullbrook 2012; Hopkins 2011; Koppelman 2009; Ikeda and Naworski 1992). In her study of twenty-six faculty members in a variety of disciplines (social sciences and sciences), Cameron (2014) suggests that pedagogical strategies used by university instructors around the world to address dominant obesity discourse have four common characteristics, namely: creating an inclusive atmosphere, starting where students are at, scaffolding information, and calling attention to how knowledge and language is socially constructed. In her study she draws upon critical pedagogy to help develop a fat pedagogy Published by NRC Research Press

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and provides examples of instructional strategies that go beyond just reducing weight bias but rather focus on reframing our understanding of the relationships between weight, health, and beauty. For example, she highlights Cooper's (2007) “headless fatties activity”, aimed at raising students' awareness of the dehumanizing images of obesity and uses the Antifat Attitudes (AFA) Scale (Morrison and O'Connor 1999) to help students recognize how biases about weight influence everyday interactions. While limited teaching resources exist, Cameron is not the only one offering instructional strategies for taking a critical approach to obesity discourse. For example, Campos (2004) suggests examining how the weight loss industry exploits cultural anxieties about fatness to engage consumers in buying weight loss products that largely do not work and how obesity studies have been largely exaggerated and misinterpreted. In addition to Cameron and Campos, the websites Teaching Tolerance (tolerance.org), Rudd Centre for Food Policy (yaleruddcenter.org), and the recently released Health At Every Size curriculum resource (Clifford 2013) offer other pedagogical ideas. While this body of literature has provided pedagogical insights into challenging weight stigma within education, less pedagogical research has been conducted within health care and even less with regards to diabetes stigma. McVey et al. (2013) help fill this gap in the literature on weight stigma reduction in health care with their pilot study exploring the impact of a daylong education session on weight bias among public health professionals (N = 342). Innovatively, a large portion of the intervention was focused on providing participants with information on the potential “negative consequences of focusing exclusively on weight instead of overall health” (McVey et al. 2013 p. 3). Within this, they emphasized that focusing on weight within health promotion could result in unintended effects like triggering unhealthy food and weight preoccupation, eating disorders, and repeated weight loss and regain. As an alternative to focusing on weight, they also educated participants on the benefits of intuitive eating. Following the intervention, weight-biased attitudes were significantly reduced. In their paper challenging current weight-based approaches to health and advocating for weight-inclusive approaches, Tylka et al. (2014) suggest that eradicating weight stigma should be the number one priority. While they highlight explicit strategies such as stigma education and spatial accommodations (for example, waiting room chairs and medical supplies that accommodate all patients across the weight spectrum), they also address the need to target internalized weight stigma and shame. They suggest that health care professionals should play key roles in (a) helping patients to reframe body blame and shame (i.e., less emphasis on weight and more on the impact of societal weight stigma) and (b) helping patients shift from body policing to more positive ways of attending to the body. While the dominant belief is that people need to be dissatisfied with their weight and (or) appearance to want to change it, the literature suggests the opposite: people are more likely to do self-care when they have positive associations with their bodies. Key principles for addressing type 2 diabetes-related stigma Given the known physiological and psychological harms of stigma, avoiding and (or) reducing type 2 diabetes-related stigma is an important aim for clinicians and educators working in this area. To avoid diabetes stigma in education, prevention, or treatment of type 2 diabetes, the following principles are recommended, as borrowed and adapted from the broader weight stigma literature. The first principle is to pay attention to language. Given the high risk of disordered eating, body image disturbances and other potential iatrogenic harms stemming from an explicit focus on weight and weight loss that may often be present in type 2 diabetes treatment and education, it follows that attention to how

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health messages are framed matters, particularly for youth. Pinhas et al. (2013), for example, in a case study of several youth with eating disorders, shows how these youth attributed their eating disorders in part to messages they received in school-based education on the importance of achieving a healthy weight through lowering caloric intake or burning calories. The authors thus recommend that a safer alternative in health education may be to focus instead on “health” not “healthy weight.” Overall, language focused around monitoring weight, dieting, or exercising has the potential to create harm. Providing youth who have or are at risk of developing type 2 diabetes with messages around the importance of active living and healthy, balanced eating for all bodies, regardless of size and shape, avoids potential iatrogenic harms of diabetes treatment and education, while still communicating essential health messages. To better understand the impact of health and weight messaging on youth with type 2 diabetes, future research could explore the impact of how health information is presented on psychological health outcomes and eating pathology among youth with type 2 diabetes. For health care providers and educators to use safe language with their patients or students, it is important for them to develop an understanding of why some language (e.g., “health” or “active living”) is preferred over other language (e.g., “healthy weight” or “dieting”). In this regard, the second principle to avoid type 2 diabetes stigma is to raise awareness among providers and educators. Areas where awareness raising is particularly important are those regarding the harms of focusing on weight, and conversely, of the benefits of a health-centered approach. The successful educational intervention on weight stigma among public health professionals by McVey et al. (2013) included a component on the consequences of weight stigma and the inadvertent harms of obesity messaging. Their intervention also provided information on the benefits of intuitive eating. Currently, research suggests that intuitive eating may have benefits that surpass potential benefits of weight-centered approaches to health (see Bacon and Aphramor 2011). An interesting example relevant to metabolic health was a study by Weinsberg et al. (2009). They found that intuitive eating was associated with increased insulin sensitivity and decreased adiposity in Latina female adolescents classified as obese. The third principle for avoiding weight bias in education and health care is to develop, use, and disseminate resources tailored towards helping raise awareness. The Rudd Center for Food Policy and Obesity, for example, has a number of resource videos on weight bias, including weight stigma in health care. One such video was found to be effective in reducing weight stigma among pre-service health students (Poustchi et al. 2013). The Rudd Center also has a toolkit on avoiding weight stigma in health care (Rudd Center 2014). Beyond these resources, materials specifically targeted towards emphasizing health, rather than weight, are also required. An existing example includes an article by Bacon and Matz (2010) on diabetes self-management through intuitive eating. May (2012) also provides a comprehensive guide on thriving with diabetes or pre-diabetes through mindful eating, an approach aligned with intuitive eating. A recent resource developed by the National Association for the Advancement of Fat Acceptance (NAAFA) specifically targeting weight bias within youth (Ikeda et al. 2014) titled “We come in all sizes,” offers case studies, key information, and additional resources on topics such as weight prejudice, fat bullying, and body dissatisfaction. It offers practical and hands on ideas for parents, teachers, administrators on how to advocate for health at all sizes. Resources such as this could be further developed for type 2 diabetes-related stigma, assessed as a means of improving health, and made widely available. Published by NRC Research Press

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Conclusion and directions for future research As we have argued through this review, type 2 diabetes stigma needs to be addressed within diabetes management, particularly for youth, to ensure that optimized care is achieved. Drawing from the weight stigma literature, we have highlighted three important ways for type 2 diabetes-related stigma to be addressed, specifically within youth. First we have highlighted that paying attention to the power of language is critical. For example, understanding the lived experience of adolescents who live with diabetes and their relationships with it may be crucial in diabetes self-care. As has been shown within the weight stigma literature, the terms “overweight” and “obesity” are often used as linguistic symbols of socially normative categories that serve to stigmatize some and privilege others. Second, we have endeavored to illustrate the need for more awareness around, of, and about obesity and type 2 diabetes-related stigma. There is a need for more resources to be developed and specific training to be conducted around how health care professionals can become more aware of their implicit and explicit biases related to obesity and diabetes. Lastly, we have highlighted the need to address weight and type 2 diabetesrelated stigma at a socio-environmental level by implementing new policies and processes that aim to reduce and eliminate stigmatizing practices that have shown to cause harm. While there is a growing body of literature on weight stigma reduction, more is needed with regards to type 2 diabetes-related stigma. Not only are standardized reporting tools needed to assess perceived, experienced, and internalized stigma, but there is also a need for more qualitative studies that focus on understanding the lived experiences of type 2 diabetes-related stigma (Schabert et al. 2013). There is also a need for more research related to health care education that looks at how to change biased attitudes and beliefs about diabetes and obesity (Teixeira and Budd 2010). Such literature would significantly help to understand and address growing concerns related to diabetes and obesity stigma and pervasive implicit and unconscious weight-related attitudes within health care.

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