Weight stigma and health – Repercussions on the health of adolescents and adults: integrative review of the literature

Objective: To conduct an integrative review in order to understand the repercussions of the social stigma of overweight on the health of adults and adolescents. Methods: The international protocol for systematic review and meta-analysis studies PRISMA was adopted to guide the writing of this review. The databases used were PubMed, Psycinfo, SciELO, Medline, Lilacs and Pepsic, considering studies published in the period from 2000 to 2020. Sixty-seven (67) articles were analyzed, and 4 categories emerged: repercussions on physical well-being; repercussions on social well-being; repercussions on mental well-being; and mixed category (physical and psychological impact). Results: In the vast majority of studies analyzed, weight stigma had a negative impact on the different spheres that make up the health construct, that is, the physical, social and mental spheres. Conclusions: The consequences of weight stigma are a source of intense suffering, with an impact that reduces the quality of life of individuals who experience stigmatization, involving physical, emotional and social aspects.


INTRODUCTION
Obesity is a condition marked by medical criteria and diagnoses, being defined as an "excessive accumulation of body fat in adipose tissue, with negative health implications" 1 and a "chronic non-communicable disease" 2 .With the establishment of the definition of obesity as a disease, fat starts to be under the strict control of medicine, and such criteria and diagnoses can even become a legitimate tool for the exclusion of these people 3 .
In contrast to current times, fat bodies were once considered synonymous with health, wealth, beauty, vitality and fertility.However, fat bodies were against Judeo-Christian ideologies that preached moderation and restriction, as well as transformations experienced in the socio-cultural and historical context 4 .With the end of the Renaissance era and the rise of Western industrialized societies, bulky bodies succinctly lost their value, and started to have no more a positive but definitely rather a pathological connotation 4 .
From these notes, it is clear that the way of seeing and understanding excess weight has changed throughout history, going through social, historical, cultural and geographical contexts, in a constant struggle between the acceptable versus the criticized 5 .Negative stereotypes related to overweight persist to the present day and are little challenged in Western society, leaving people with overweight vulnerable to social injustice and impaired quality of life, as a result of substantial disadvantages and stigma 5 .
Stigma arises from the characteristic of societies of defining categories about the attributes considered normal or common to human beings, creating a social identity 6 .Thus, individuals who have characteristics deviating from these attributes are considered to carry a stigma 6 .In view of this, the stigmatized individual is one whose social identity includes any attribute that frustrates the expectations of normality observed by the society in question, which ceases to consider him a common creature and starts to reduce him to weakness, defect, disadvantage or discredit 6 .
The stigma associated to excess weight consists in the depreciation of an individual for having a weight above that considered ideal for a given society 6 .An individual's weight is a visible, particular physical characteristic that cannot be hidden, and is also one of the first aspects observed in a person 5 .In this context, it can be said that the individual with overweight suffers a strong social stigma, as he is considered disqualified for complete social acceptance, suffering exclusion in various situations, and may even experience the deterioration of his social identity and personal trust 6 .Personal (microsocial) stigma, that is, the individual psychological process in which an individual goes through situations in which they experience prejudiced and discriminatory attitudes, is the most common type of stigma.However, studies on the subject describe that there is an alternative form of prejudice and discrimination practiced by policies of private and governmental institutions that restrict the so-called structural stigma as an opportunity for stigmatized (macrosocial) groups 7 .
In addition, both forms of stigma have consequences.The personal stigma experienced through individual attack can cause the internalization of stigma, causing thoughts and behavior based on the race that the bulky body is distorted and immoral, which is called self-stigma 7 .On the other hand, structural stigma can happen in an explicit way, as it happens in cases of bullying, or even come disguised as a health discourse 7 .The construction of a totally biological and medical idea of obesity replaces traditionally constructed moral causes 4 .In this way, a justification is created to "fight" against it and the duty to help and treat without the guilt of the moralizing gaze, creating a pretext for everyone to attack the obese patient and face this as an attempt to fight obesity 4 .This leads to common sense and even certain specialists in medical ethics affirm that stigmatizing, with high weight and applying social pressure is effective in stimulating weight loss and improving the health of this population 8 .The most recent science, however, indicates that weight stigma can trigger physiological and behavioral changes linked to poor metabolic health and increased weight gain 8 .
Considering the current hegemony of the lean and "healthy" body pattern, it is observed that the discrimination of fat bodies has been increasingly naturalized, even in the medical field 9 .Negative attitudes of health professionals towards obesity can compromise the dignified and humanized professional practice, implying a decrease in the quality of care provided to patients presenting the condition of obesity, making people living with obesity to avoid health services and impeding their adherence to treatment 10 .
Weight-related prejudice and stigma can result in discrimination and harm the human rights, social rights and health of those affected 11 .Despite being less studied, perhaps because it is more socially acceptable, weight stigma is a serious theme, and in some cases, more prevalent than racism, sexism and other forms of bias 5 .In many countries, it is not illegal for individuals with overweight or moderately obese to be denied services or opportunities based on their weight 12 .In this sense, there is a clear need to combat weight stigma, which is widespread throughout the world.Minimizing this stigma is likely to have a positive impact on the health of individuals who experience it 13 .
Previous reviews proposed the investigation of the association between weight stigma and biopsychosocial consequences of stigma in adults with overweight/ obesity 14,15 .However, to the best of our knowledge, this is the first time that an integrative review evaluates the association of the social weight stigma on health, as a multidimensional concept that involves physical, mental and social well-being of adults and adolescents with overweight and obesity.

METHODS
This is an integrative review of the scientific literature whose aim is to synthesize the knowledge on a given subject, discussing it critically and allowing to observe trends and gaps that require further research 16 .
The procedure carried out in this review involved the following steps 16 : (1) identification of the theme and guiding question; (2) establishment of inclusion/exclusion criteria; (3) categorization of studies; (4) evaluation of studies; (5) interpretation of results; and (6) synthesis of knowledge.The international protocol for systematic review and meta-analysis studies PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) was adopted to guide the inclusion and exclusion of articles and the writing of this review 17 .
The research question was "what are the repercussions of the social stigma of overweight on the health of adolescents and adults?".

Indexing bases and keywords
The search for articles was carried out in the Pubmed, Psycinfo, Scientific Eletronic Library Online (SciELO), National Library of Medicine (Medline), Latin American and Caribbean Literature in Health Sciences (Lilacs) and Electronic Psychology Journals (Pepsic) databases.Indexed descriptors were used for the search, according to the DeCs/ MeSh standardization, in its Portuguese and English versions.The search terms used were: "Estigma Social" (social stigma), "Preconceito" (prejudice), "Obesidade" (obesity), "Sobrepeso" (overweight) and "Peso Corporal" (body weight).

Inclusion and exclusion criteria
Criteria for inclusion of articles in the review were: (a) studies published between January 2000 and December 2020; (b) studies that directly addressed the topic of interest; (c) empirical studies; (d) published in Portuguese, English and Spanish, (e) studies that aimed to investigate the consequences of weight stigma on some health outcome.
The following articles were excluded: (a) materials such as monographs, editorials, books, book chapters, reviews and abstracts in conference proceedings; (b) theoretical articles and literature reviews; (c) studies on the elaboration and validation of instruments; (d) studies that dealt with weight stigma in children, since the objective of the review was to understand the consequences of weight stigma for adults and adolescents; (e) studies conducted with subjects who underwent bariatric surgery; (f) studies in which weight stigma has been associated with other types of stigma, such as racial and gender.

Data collection and analysis procedures
For the selection of articles, an evaluation was carried out by two independent judges, obeying the following order: (1) reading of titles of all identified studies; (2) reading of abstracts of the studies selected in the previous phase; and (3)  complete reading of the selected texts.In cases where there was disagreement between the judges as to the adequacy of a study, an evaluation by a third judge occurred.After the exclusion of articles that did not meet the inclusion criteria, a listing of those composing the final corpus of analysis of this study was made, describing the following information: title, authors, year and place of publication, database, design, sample, instruments used to assess weight stigma, main objectives and main results.The full analysis of the articles allowed the construction of categories, in order to answer the guiding question of this review.
The categories were structured according to the sphere of health affected by the repercussions of weight stigma.World Health Organization's (WHO) concept of health, that is, the physical, social and mental well-being 18 , was used to support this categorization.Within the sphere of "physical well-being" 15 , issues related to biological health itself or any behavior that directly affected it were considered.Therefore, impacts on physical well-being were considered: sedentary lifestyle; weight gain/loss; physical pain; functional capacity; seek health care; cardiovascular, inflammatory, lipid, cortisol, glycated hemoglobin index and metabolic dysregulation.For "social well-being" 10 , the impacts on interpersonal, professional relationships and the effect of stigma on the general social coexistence of individuals with overweight were considered.Finally, "mental well-being" 15 was considered to have any impact on psychological health, such as: eating disorders, self-esteem, quality of life, psychosocial function, loneliness, levels of depression and anxiety, coping, cognitive performance, developing of dementias and higher suicide rate.

Study characteristics
The searches in the databases resulted in a total of 5,681 articles.In the first stage of the analysis, 3,767 articles were excluded because they were duplicates.Then, 1,914 were excluded mainly because they did not directly address the topic of interest.There were 250 articles left to read in full length and, after this reading, 183 were excluded, leaving a total of 67 articles which made up the final corpus of this review.Figure 1 shows the flowchart of strategy for selecting studies according to PRISMA guidelines.
An important portion of the studies was developed exclusively with the female audience (n = 14, 20.8%), and only 01 study (1.7%) proposed to analyze male individuals.Higher prevalence of the female population was recurrent also in studies with mixed samples (n = 45), where women represented more than half of these samples.Regarding body mass index (BMI), the samples ranged from 21.0 kg/m² to 49.0 kg/m².Such variation was due to the fact that some studies included control groups with BMI within the normal range in their samples.The average BMI of the studies was 28,8.0 kg/m² (Table 1).
An average distribution of 3.3 publications on the theme was per year, with the years 2016, 2018 and 2019 having the highest number of studies published, with 08 articles (13.7%) each.With the exception of the intervals between the years 2000-2004 and 2006-2007, that there were no publications on the impact of weight stigma on health, the year with the lowest number of publications was 2010, with only 01 study (1.7%).Despite the large number of countries producing studies on the topic (12 countries), such studies were concentrated in North America (n = 45, 67.1%) (Table 1).
For the structuring of the results of the studies, the repercussions of weight stigma were organized according to the sphere of health affected.In this way, repercussion of weight stigma were found in the three spheres of the WHO's concept of health, that is, the physical, mental and social well-being 18 .In addition, a fourth category was included to list the results of studies that highlighted the impact of weight stigma on more than one proposed health sphere.Reports of experiences of weight stigma predicted higher levels of current reported exercise behavior.The internalization of weight bias was negatively correlated with motivation and self-efficacy of exercise, and was associated with lower levels of reported exercise behavior.2015, USA 23 Testing whether self-reported weight discrimination is related to worse outcomes related to diabetes.
Quantitative; Daily Discrimination Scale.
The attribution of self-reported weight discrimination was associated with a higher rate of diabetes, more emotional distress due to diabetes and fewer days of participation in diabetes self-care activities.2016, USA 24 Assess whether weight-related discrimination triggers multisystem deregulation.
Quantitative; Selfreporting of cases of perceived discrimination in interpersonal relationships on a day-today basis, both in the baseline and in 10-year follow-up surveys.
Long-term weight discrimination was associated with more than twice the risk of high allostatic; experiencing weight discrimination seems to promote many of the pathological characteristics of obesity.2017,UK 25 Examine the association between the perception of weight discrimination and self-reported physical activity.Quantitative; Instrument developed by the authors.
Participants with experience of weight stigma were less likely to believe that weight was controllable, which could reduce the motivation to engage in exercise for weight control purposes.2017, USA 26 Examine the role of weight stigma as potential contributors to maintaining weight loss and weight recovery.Quantitative; Instrument developed by the authors.
Heavier women had lower quality ratios and predicted they were less likely to remain intact.

2013, Germany 35
Examine whether obese job seekers are treated or behave differently than non-obese candidates.Quantitative; Instrument developed by the authors.
The results support the connection between weightbased teasing and lower levels of psychological well-being as well as low self-esteem and higher levels of depression, low physical self-concept and less effective physical fitness.2014, USA 50 Examine the moderating role of external discrimination and weight-based selfdiscrimination in the relationship between BMI and health-related quality of life.Quantitative; Public aid subscale.Social stigma related to obesity was the most important determinant of quality of life in the adverse effect of obesity on how Caucasian women valued their health.Obesity-related sexual function impairment was the most important contributor for African American women, and the adverse impact of obesity on professional life was the most important factor for Hispanic women.2015, USA 54 To assess whether stigma or self-stigma is associated with factors that affect vulnerability to stress among overweight and obese medical students.Quantitative; Crandall's Anti-Fat Attitudes Questionnaire, Fat-Thin IAT and Everyday Discrimination Scale.
Participants had worse general health and low self-esteem than students with normal weight, as well as high risk of stress, risk of professional burnout, low professionalism and empathy, lower academic performance, poor mental health, higher risk of substance abuse and suicidal ideation.2015, UK 55 Investigate the extent to which perceived weight discrimination mediates quality of life, life satisfaction and depressive symptoms.
Quantitative; Instrument developed by the authors.
Individuals who reported experiences of weight discrimination had worse psychological well-being in all three domains.2016, USA 56 Test the relative effects of BMI and weight-based peer discrimination on increasing emotional problems.Quantitative; Weight Self-Stigma Questionnaire (WSSQ).
Discrimination experiences, both unmasked and subtle, are positively related to self weight stigma in people with obesity; and negative beliefs about yourself increase the chance of developing depression and anxiety problems.2018, UK 63 Examine whether concerns about weight stigma explain why individuals who perceive their weight status as being overweight are at increased risk of overeating.Quantitative; Crandall's Anti-Fat Attitude Scale.
Greater anticipated rejection impaired cognitive performance, judgment of one's appearance and social self-esteem, more negative emotions, more stressful interaction, more rumination, more reported efforts to compensate and more spontaneous thoughts related to anxiety and evaluative concern.2018, Netherlands 68 Testing the suggestion that the internalized weight bias predominantly reflects threats to morality.561 participants; 52% women; mean age 47 years; mean BMI 28.
The stigma of weight that emphasizes that overweight and obese people is immoral gives rise to fear of condemnation and will lead to preferences for responses that will allow to show quickly and visibly to others that someone is willing to improve and change behavior.2019, USA 69 Examine the association between weight discrimination and multiple domains of cognitive function.Weight discrimination was associated with an about two-fold increased risk of poor performance on tasks that measured episodic memory, speed-attention, visuospatial ability, and numeric reasoning.2019, USA 70 Examine the experienced and internalized weight stigma and its associations with health.Weight bias internalization is associated with more use of coping strategies with the potential to harm health (e.g., disordered eating, substance use, self-blame), while more lifetime experiences of weight stigma appear to be associated with more attempts to cope in general.2020, USA 76 Examined whether anticipated weight stigma may explain the relations between weight discrimination and disordered eating.
297 participants recruited through a online data collection; 52% women; mean age 31 years; mean BMI 27.
Greater experiences with weight discrimination were indirectly associated with disordered eating behaviors and cognitions (eg: cognitions related to eating disorders) via anticipated weight stigma.2020, UK 77 Determine whether weight related self-stigma predicted worsening "food addiction" over time.
Quantitative; Yale Food Addiction Scale, and Weight Self-Stigma Questionnaire.
Fear of stigma but not self-devaluation was associated with worsening "food addiction" symptomatology over time.

Physical and psychological well-being
2009, USA 78 To investigate whether weight stigma is associated with obesity-related morbidity.
Quantitative; Instrument developed by the authors.
The stigma associated with obesity plays a role as a determinant of self-rated health, however, it may not be an important explanatory variable in the association of BMIhypertension.2012, USA 79 Investigate whether overweight individuals experience threats of social identity in situations that trigger concerns about weight stigma.
Women who believed that their weight would be visible to the evaluators, the higher the BMI, the greater their reactivity to stress and the more cognitively impoverished.2015, USA 80 Investigate whether BMI and self-reported psychological health and physical health are mediated by past discrimination experiences and stigma concerns.
Quantitative; Instrument developed by the authors.
Perceived discrimination harms psychological and physical health, raising concerns about future stigmatization.
2016, USA 81 Examine the relationship between the perception of weight discrimination and change in health markers in approximately 10 years.
Quantitative; Instrument developed by the authors.
The results indicate that weight discrimination is associated with worse physical and mental health over time.
2018, USA 82 Identify how "overweight" endurance athletes experience stigma and how it affects their mental and physical health, as well as their participation in endurance sports.
The perceived stigma was what led most of the athletes to train indoors, however, after the initial discomfort of moving to public environments, none of the participants indicated that they had participated less in the chosen sport because of the perceived stigma.2020, USA 83 Assessed whether prepandemic experiences of weight stigma predicted maladaptive eating behaviors, physical activity, stress, and depressive symptoms during the spring and early summer months of the COVID- Qualitative; Instrument developed by the authors.
The stigma brought serious psychosocial repercussions, such as behavior and attitudes of social isolation, deprivation of conjugal intimacy, withdrawal from work, concealment of the body and physical illness.2020, Brazil 85 Investigate, qualitatively, fat Brazilian women's perceptions of their own bodies and their experiences with weightrelated discriminations, and how these experiences affect their well-being.
Qualitative; semi-structured interview developed by the authors.
Having a larger body was related to physical (e.g., body pains, unwillingness to perform activities) and psychological (e.g., low self-esteem, less social engagement) consequences.Furthermore, the participants voiced negative attitudes towards themselves and a hateful relationship with their own bodies.

Impact on physical well-being
Of the studies found, 22.4% (n = 13) dealt with the impact of weight stigma on physical well-being, more specifically assessing the effect of stigma on structural and biological factors such as: greater tendency towards sedentary lifestyle; increase and/or difficulty in losing weight; increased physical pain; decreased perception of functional capacity; avoidance to seek health care; cardiovascular, inflammatory, lipid and metabolic dysregulation; changes in cortisol levels; and elevation of glycated hemoglobin index.One of the consequences of weight stigma that draws attention is the tendency for greater weight gain (or less loss), because such a result could perpetuate the stigma.One study pointed out that, over four years, there was an average increase of 1.66 kg among individuals who reported experiences of weight discrimination 21 .Weight gain has been more frequently placed as a risk factor for increased physical pain and, although it is possible to explain this relationship with physiological reasons, it is also correct to state that the stress induced by the experience of weight stigma can be involved in the case of individuals having more physical pain with and without associated medical conditions 29 .
It is also important to draw attention to the results of studies that found a positive association between perceived weight discrimination and physiological dysregulation, as measured by cardiovascular, inflammatory, lipid and metabolic dysregulation 30 ; as well as a negative association between stigma and excess weight and allostatic load (measured using 7 systems: sympathetic and parasympathetic nervous system, hypothalamic-pituitary adrenal axis, cardiovascular functioning, general and lipid metabolic activity, glucose metabolism, and inflammatory system) and, potentially, morbidity and mortality from chronic diseases 24 .
Although overweight and obesity are the main contributors to the increased prevalence of type 2 diabetes and comorbidities, self-reported weight-related discrimination showed to be associated with elevated glycated hemoglobin index, greater emotional distress due to diabetes, fewer days of participation in self-care activities and even non-adherence to behaviors essential to the success of diabetes treatment, such as a balanced diet, exercise and regular blood glucose monitoring 23 .

Impact on social well-being
Only 8.9% (n = 6) of the studies addressed direct social impacts caused by weight stigma.The results showed that, in this sphere, there are differences between the sexes, and the most affected were women with obesity.In addition, weight stigma causes women to tend to maintain relationships of lower quality and stability or even to avoid building new relationships 36 .
Regarding the repercussions of weight stigma in the sphere of work, it was noted that men with overweight and obesity and women with overweight did not suffer discrimination in terms of access to programs that were part of active labor market policies or in their labor and wages outcomes.The only group that experienced negative results in the job market was the group of women with obesity.Despite making more job applications and becoming more involved in vocational training programs, they had worse job results, and were less likely to be employed than normal weight women and more likely to earn less in terms of hourly wages 35 .In addition, women with obesity commonly experienced work-related discrimination, humiliation, provocation or social isolation at the workplace 37 .

Repercussions on mental well-being
The studies that aimed to verify the impact of weight stigma on mental well-being were the majority in the corpus of the present review (59.7%, n = 40).Among the findings, the consequences of weight stigma on mental well-being stood out, including: dysfunctional eating behavior (quantity and quality of food eaten), eating disorders (binge eating and bulimia), low self-esteem, worse psychological well-being in quality of life and life satisfaction domains, bad psychosocial function, lower levels of physical self-concept and selfefficacy of physical fitness, depreciation of appearance, more stressful interactions, more rumination, greater perception of loneliness, higher levels of depression and anxiety, maladaptive coping, worse cognitive performance, worse working memory performance, higher probability of developing dementias and higher suicide rate.
Based on the results of studies that aimed to understand the impacts of weight stigma on dysfunctional eating behavior (n = 11), it is possible to conclude that weight stigmatization is related to binge eating among samples of university students 42 , adults in general 46 and men 70 .In the latter study, in addition to binge eating, depressive symptoms, dietary restrictions aimed at losing weight and worse self-reported health were identified as consequences of weight stigma 70 .Concerns about weight stigma partially explained the relationship between perceived overweight and overeating 63 .
Only three studies evaluated samples with subjects under 18 years of age, all of which were related to the repercussions of weight stigma on mental well-being, indicating the impact of this stigma on the psychological distress of adolescents.Young people who experienced weight stigma showed low self-esteem, higher levels of depression, and lower levels of physical self-concept and self-efficacy of physical fitness than adolescents who did not experience this situation 49 .In addition, the way school-age young people perceived the treatment of peers based on their weight made them more dissatisfied with their bodies and more anxious, lonely and sick 56 .Still in this discussion, it is important to highlight that the assessment of weight stigmatization throughout life has the potential to deteriorate the health of individuals in the long run 57 .
In a sample of 1,000 participants, it was observed that the high perception of loneliness occurred more frequently in individuals with obesity and was related to depressive symptoms, greater self-stigma and weight discrimination 71 .This characteristic was also observed in a specific population of women looking for surgical procedures to treat obesity.It was observed that the frequency with which experiences of stigmatization related to weight occurred were associated with a greater perception of loneliness, which in turn was associated with a higher rate of suicide, with 30.3% of the women reporting suicidal thoughts, 11.1% somewhat serious suicidal ideation, 7.6% suicide attempt/plan, and 5.6% lifelong suicide attempt 47 .
Important aspects related to cognition can also be affected by the experience of stigmatization by being overweight.A study with a longitudinal sample showed that, over a 10-year period, there were 40% more cases of dementia than would be expected, based on the initial profile of the participants, among individuals who reported experiencing weight discrimination 64 .In this same perspective, the working memory performance also seems to be an aspect affected by weight stigma.It was found that such an aspect of cognition may be lower in individuals in whom concerns related to overweight stigma became prominent 65 .

Mixed category (physical and psychological impact)
Of the studies analyzed, 11.9% (n = 8) found results that demonstrate the impact of social stigma in more than one sphere of health.Some of the main impacts of this category are: increased blood pressure as a result of a stressful situation, which can generate an attention deficit; increased physical pain and psychological illness; and difficulty in finding clothes and equipment suitable for the practice of physical activity by individuals with obesity that can generate physical accidents and contribute to negative self-concept and body image results among these subjects.
Individuals who experience discrimination report more daily stressors over the course of a normal week, experience more physical symptoms (body pains, for example) and feel more negative affect (sadness, anger) and less positive affect (joy, pride) than individuals who do not experience weight discrimination.In addition to physiological responses to weight stigmatization experiences, individuals who perceive weight discrimination are more vulnerable to stressors in the course of their daily lives.The impact of these stressors is likely to accumulate over time and may be a mechanism by which weight discrimination is associated with poorer health over time 81 .
In a very specific sample of medical students with overweight and obesity compared to normal weight students, a worse general health condition was observed (symptoms of fatigue -chronic tiredness, headaches, dizziness, sore muscles, etc.) and low body esteem among the individuals with overweight and obesity, placing them at high risk of stress and also professional exhaustion, low professionalism and empathy, lower academic performance, low mental health, higher substance abuse and suicidal ideation 54 .
In this category, there was a study that disagreed with the impact of weight stigma on blood pressure.The hypothesis was tested in a cohort of individuals from the Dominican Republic, a culture that values the fat bodies over thin ones.This study highlighted that the stigma associated with obesity plays a determining role in self-rated health, that is, people who have a preference for larger bodies have a tendency to feel better about their health, even though they are overweight.Perhaps for this reason, in this study, it was found that stigma may not be an important explanatory variable in the association between BMI and hypertension 78 .

DISCUSSION
The aim of the present study was to carry out an integrative review of the growing body of research studies that investigate the repercussions of the social stigma of overweight on the health of adults and adolescents.The results showed that, in the vast majority of studies analyzed, weight stigma had a negative impact on the health.The most studied dimension of health analyzed in the recent literature was the mental well-being.
Contemporary society attributes negative values and stigmas to subjects who have a fat body, and this characteristic ends up becoming an undesirable social, moral and identity mark, which disqualifies subjects because they do not fit the current body standards 86 .Individuals living with overweight often experience situations of stigmatization and are submitted at all times with media information about how their body should be 14 .Consequently, these subjects, affected by the stigmatization of their social environment, agree with the negative attitudes and blame themselves for being overweight 5 .Thus, there is an internalization of stigmatizing attitudes, and individuals who live with excess weight start to believe in their physical and moral disbelief 5 .This is one of the mechanisms through which weight stigma has been associated with depression, anxiety and other psychological correlates 14 .It was noteworthy that there were higher levels of depression and an increase in the frequency of discrimination experiences among individuals with a higher BMI 71 .
The shame of showing the body or exposing it to social situations are another mechanism through which weight stigma causes damage to the health of people with overweight 87 .Due to shamed of their weight/body and fear of judgments, including by health professionals, these individuals avoid seeking health care and also feel uncomfortable about exercising in public, and this ultimately makes them more sedentary 87 .It is worth noting that the fear of judgment on the part of health professionals is a consequence of the treatment given by most of them.That was observed in studies that found that physical therapists 88 , occupational therapists 89 , physicians, nurses, and other professionals of a university hospital 90 , maintained harmful attitudes and stereotyped beliefs about obesity.Acording to these studies, this professionals use to judging patients according to negative adjectives as often as the general population, and this could result in the non-involvement of people living with obesity with the health system 91 .
It is worth mentioning the question of anticipated expectation of rejection, a psychological mechanism in which individuals who anticipate being stigmatized.This make people whith overweight avoid putting themselves in situations where they fear suffering stigma, preventing them from applying for certain jobs, participating in social events, and seeking medical care 92 .Given the extent of the weight bias and discrimination in our culture, individuals with overweight or obesity are likely to encounter numerous situations in which they anticipate rejection based on their weight 92 .They are, therefore, susceptible to experiencing threats of social identity and its deleterious cognitive, affective and physiological effects, chronically associated in their daily lives.
In this light, it is clear that weight stigma causes consequences that unfold and are perpetuated in other areas of the lives of individuals who experience such a situation.Low intelligence, for example, is a stereotyped characteristic commonly attributed to individuals with obesity 5 .Due to the anticipated expectation of rejection, individuals with obesity are at risk of confirming this stereotype whenever their cognitive functioning is under evaluation, perpetuating internal consequences such as low self-esteem, stress, anxiety, depression, and external consequences such as difficulty finding a job or relating to other people 93 .
Physiological aspects that are apparently not linked to the social sphere, such as inflammatory, lipid, metabolic and cardiovascular regulation, seem to be directly and indirectly affected by the experience of weight stigma, and are associated with multiple chronic health conditions 94 .In this sense, it is possible to point out that the repercussion of obesity on the physiology of the body goes beyond physical aspects and includes an important influence of stigma 94 .Furthermore, high levels of cortisol, which have been associated with experiences of weight stigmatization, suggest that these experiences can sharply increase the response to stress and compromise its regulation; this, in turn, can increase sensitivity to stress in general and lead to the development of several health problems.Thus, discrimination based on weight can increase the medical burden associated with obesity 94 .
Ayaka Tomiyama proposed the "cyclic obesity/weightbased stigma model", named by the acronym COBWEBS, which theorizes, among other questions, that weight stigmainduced stress initiates a cascade of behavioral, emotional and physiological responses 95 .The modal response in any of these domains causes weight gain, either directly, through stress-induced cortisol secretion, or mediated by coping attempts that promote eating and weight gain 95 .Such a model helps to explain part of the results found, especially with regard to the increase in the probability of gaining weight and the decrease in the chances of losing weight, greater propensity to binge eating and increased tendency to eat in response to mood changes 95 .
This model also characterizes weight stigma not as a static construction, but as a "vicious cycle" -a positive feedback cycle in which weight stigma generates weight gain through increased food consumption and other behavioral biological mechanisms.The net effect of this process is to promote weight gain, which exposes individuals to greater experiences of weight stigma, triggering the cycle again 95 .
It is known that being overweight can be directly associated with the appearance of chronic health conditions such as kidney disease, cancer, diabetes, sleep apnea, liver disease, high blood pressure and cardiovascular diseases 96 .However, based on this review, some physical symptoms were intensified because of weight stigmatization.This finding is possibly related to the fact that, contrary to what is desired, weight stigma takes individuals away from healthy and self-care behaviors 23 .
Regarding sex distribution in the samples, it was observed that studies in the literature on weight stigma are mostly focused on one group, the female 27 .The scarcity of researches aimed at assessing weight stigma and its repercussions on the health of men is due, in part, to the perceptions that women are more affected by body image and stigma than men 97 .However, according to the results of studies that included men in their samples, it is possible to state that this population is also affected by weight stigma.Greater attention has to be given to men and their relationship with weight stigma both in research and in the clinical practice of health professionals.Overweight was diagnosed in about half of men and women, and the prevalence of obesity was 12.5% and 16.9% for men and women, respectively.These data reinforce the importance of shedding light on the issue of weight stigma in men, since the male population represents a large portion of the population with overweight 98 .
In addition, it is worth noting that, because it is a very complex condition that indirectly reunites a series of repercussions in the psychosocial spheres 10 , it is clear that, despite the didactic division made in the present review to better visualize the consequences of stigma on health, they all permeate the emotional sphere.This is because, although the weight stigma is a social process, it directly affects the individual's relationship with his own identity.
The negative repercussions of weight stigma on people's health are mostly confirmed by quantitative studies, what hinders a further deepening in the issues involved in this process.Another point to be considered concerns the small number of studies that have proposed to study the male population, which also suffers the consequences of weight stigma, and should be a target of future investigations.The absence of national studies in this review indicates a great gap in Brazilian scientific production on this topic and stresses the importance of moving forward to minimize this gap.
The strength of this review includes the categorization of the findings within a globally accepted health concept and perspective.With regard to limitations, it is assumed that the cut of the age group ends up restricting the understanding of the impacts of weight stigma in childhood.In addition, the decision not to include stigma consequences in specific contexts, such as performing bariatric surgery, can also be seen as a limitation of the study.

CONCLUSION
The results of this review indicate that weight stigma causes negative repercussions on the physical, social and emotional well-being of subjects with obesity and overweight.These repercussions go far beyond the issues generated by excess weight itself and result in important losses in physical and mental health, and in the quality of life of these individuals.

INDIVIDUAL CONTRIBUTIONS
Bruna Barbosa Siqueira -Worked on the study design, data collection and analysis, interpretation of results and writing of the text.Marina Cunha Assumpção -Worked on data collection, as second judge in the selection of articles, and assisted in the writing of the article.Sabrina Martins Barroso and Camila Cremonezi Japur -Critically reviewed and approved the final version of the article.Fernanda Rodrigues de Oliveira Penaforte -Worked on the study design, interpretation of results, writing of the text, critical review and approval of the final version of the article.

Table 1 .
Studies that aimed to investigate the consequences of weight stigma on health outcomes