Obesity, Bias, and Stigmatization

Obesity, Bias, and Stigmatization

The social consequences of being overweight and obese are serious and pervasive. Overweight and obese individuals are often targets of bias and stigma, and they are vulnerable to negative attitudes in multiple domains of living including places of employment, educational institutions, medical facilities, the mass media, and interpersonal relationships.

What is weight stigma?
Stigma and bias generally refer to negative attitudes that affect our interpersonal interactions and activities in a detrimental way. Stigma may come in several forms, including verbal types of bias (such as ridicule, teasing, insults, stereotypes, derogatory names, or pejorative language), physical stigma (such as touching, grabbing, or other aggressive behaviors), or other barriers and obstacles due to weight (such as medical equipment that is too small for obese patients, chairs or seats in public venues which do not accommodate obese persons, or stores which do not carry clothing in large sizes).  In an extreme form, stigma can result in both subtle and overt forms of discrimination, such as employment discrimination where an obese employee is denied a position or promotion due to his or her appearance, despite being appropriately qualified.

Where does weight stigma occur?
Weight stigma occurs in multiple settings by a range of individuals. For example, in employment settings, overweight people may face bias from several sources. Experimental studies have found that when a resume is accompanied by a picture or video of an overweight person (compared to an "average" weight person), the overweight applicant is rated more negatively and is less likely to be hired.  Other research shows that overweight employees are ascribed multiple negative stereotypes including being lazy, sloppy, less competent, lacking in self-discipline, disagreeable, less conscientious, and poor role models. In addition, overweight employees may suffer wage penalties, as they tend to be paid less for the same jobs, are more likely to have lower paying jobs, and are less likely to get promoted than thin people with the same qualifications.

In school settings, students who are overweight or obese can face harassment and ridicule from peers, as well as negative attitudes from teachers and other educators. At the college level, some research shows that qualified overweight students, particularly females, are less likely to be accepted to college than their normal weight peers.

In medical facilities, biased attitudes toward obese patients have been documented among physicians, nurses, psychologists, dieticians, and medical students, and include perceptions that obese patients are unintelligent, unsuccessful, weak-willed, unpleasant, overindulgent, and lazy.  One alarming consequence of negative attitudes by health care professionals is that obese patients may avoid obtaining medical care because of these negative experiences. Research has demonstrated that heavier patients are more likely to cancel and delay appointments and preventive health care services, particularly among women who are overweight or obese.

What are the consequences of weight stigma?
For obese adults, research has documented that individuals who experience weight stigmatization have higher rates of depression, anxiety, social isolation, and poorer psychological adjustment. Some obese adults may react to weight stigma by internalizing and accepting negative attitudes against them, which may in turn increase their vulnerability to low self-esteem. Because societal messages often perpetuate beliefs that weight is under personal control, obese persons may be less likely to challenge stereotypes because they can attempt to escape stigma by losing weight. Stigma may also have negative consequences for eating behaviors by interfering with weight loss attempts and leading some adults to eat more food in response to stigmatizing encounters. Stigma also has implications for physical health in the context of avoidance of health care services due to bias in medical settings. It is not known whether, or to what degree, stigma exacerbates poor self-care behaviors or contributes to additional complications and co-morbidities of obesity.

How are children affected by weight stigma?
Children who are overweight and obese are also targets of stigma and may be especially vulnerable to the consequences of bias. Negative attitudes towards obese youth develop in children as young as three years old, and children attribute multiple negative characteristics to overweight peers including being mean, stupid, ugly, unhappy, lazy, and having few friends. Peers are common perpetrators of weight-related teasing and derogatory names, and school is a frequent venue where stigma occurs.

Bias and stigma have negative implications for emotional well-being in children. Research shows that children who are targets of weight stigma internalize negative attitudes and engage in self-blame for the negative social experiences that they confront.  Research on adolescents has documented that weight-based teasing is associated with low self-esteem and depression, and that overweight teens are more likely to be socially isolated. Most alarming are recent studies demonstrating a positive association between obesity and suicidal attempts among youth.

How can weight stigma be reduced?
Professionals in the obesity field, both researchers and clinicians, can employ a variety of strategies to help reduce weight stigma and improve attitudes. Health professionals can make a difference by becoming aware of their own biases, developing empathy, and working to address the needs and concerns of obese patients.

Some specific strategies for health professionals are outlined below:

1.  Consider that patients may have had negative experiences with other health professionals regarding their weight, and approach patients with sensitivity

2.  Recognize the complex etiology of obesity and communicate this to colleagues and patients to avoid stereotypes that obesity is attributable to personal willpower

3.  Explore all causes of presenting problems, not just weight

4.  Recognize that many patients have tried to lose weight repeatedly

5.  Emphasize behavior changes rather than just the number on the scale

6.  Offer concrete advice, e.g., start an exercise program, eat at home, etc., rather than simply saying, “You need to lose weight.”

7.  Acknowledge the difficulty of lifestyle changes

8.  Recognize that small weight losses can result in significant health gains

9.  Create a supportive health care environment with large, armless chairs in waiting rooms, appropriately-sized medical equipment and patient gowns, and friendly patient reading material.

It is also useful to identify one’s own bias. Asking the following questions can be helpful in this regard:

1.  Do I make assumptions based only on weight regarding a person’s character, intelligence, professional success, health status, or lifestyle behaviors?

2.  Am I comfortable working with people of all shapes and sizes?

3.  Do I give appropriate feedback to encourage healthful behavior change?

4.  Am I sensitive to the needs and concerns of obese individuals?

5.  Do I treat the individual or only the condition?

References and Resources:

Amy NK, Aalborg A, Lyons P, Keranen K. Barriers to routing gynecological cancer screening for White and African-American obese women. In J Obes. 2006; 30: 147-155.

Brownell KD, Puhl R, Schwartz MB, Rudd L, eds. Weight Bias: Nature, Consequences, and Remedies. New York: Guilford Publications; 2005

Latner JD, Stunkard AJ. Getting worse: The stigmatization of obese children. Obes Res. 2003; 11: 452-456.

Neumark-Sztainer D, Story M., Faibisch L. Perceived stigmatization among overweight African-American and Caucasian adolescent girls. J Adolesc Health. 1998; 23: 264-270

Neumark-Sztainer D, Story M,  Harris T. Beliefs and attitudes about obesity among teachers and school health care providers working with adolescents. J Nutr Education. 1999; 31: 3-9.

Puhl R, Brownell KD. Bias, discrimination, and obesity. Obes Res. 2001;9:788-805.

Roehling MV. Weight-based discrimination in employment: Psychological and legal aspects. Pers Psychol. 1999; 52: 969-1017.

Schwartz MB, O’Neal H, Brownell KD, Blair S, Billington C. Weight bias among health professionals specializing in obesity. Obes Res. 2003;11:1033-1039.

For additional resources on weight stigma, including academic articles, PowerPoint presentations, and measures to assess weight bias, please visit www.yaleruddcenter.org and click on “Weight Bias.”