Weight Bias and Stigma

As obesity rates continue to rise in the United States and throughout the world, the bias toward those individuals who struggle with weight also climbs. Weight bias, the discrimination against those who carry excess weight, can be both explicit or implicit. Explicit weight bias is bias toward a person who carries excess weight, and the holder of the bias is aware of the discrimination that they wield against the overweight person. With implicit bias, the individual who harbors the bias is often unaware that they have bias against persons with overweight or obesity. Unfortunately, the bias against those with overweight and obesity is widely accepted and has become one of the most prevalent forms of bias. So why is weight bias important? Why have we chosen to dedicate an entire module in this text to weight bias? It is time to find out.

In this module, we do the following:

  • Explore how weight bias and stigma contribute to energy storage
  • Learn how early life interactions influence weight bias
  • Determine the negative impact of weight bias on health outcomes
  • Acknowledge how health professionals (much like those in the public) harbor implicit and explicit weight bias
  • Look at national and international trends in weight bias and its affect on quality of life on the individuals who experience such bias.

To help focus your learning on weight bias, we pose three multiple-choice questions at the beginning of this module regarding the topic of weight bias. By the end of this module you should be able to answer them correctly.

Question 1. What is the average age at which infants/toddlers begin to demonstrate signs of weight bias?

  1. 12months 
  2. 20 months
  3. 32months 
  4. 48months

Question 2. Weight stigma has not been associated with which of the following in individuals?

  1. Disordered eating
  2. Metabolic syndrome(a predisposition to type 2 diabetes mellitus)
  3. Hypertension(elevated blood pressure)
  4. High triglyceride levels(elevated levels of bad cholesterol)
  5. Low levels of high-density lipoproteins (HDL;a type of good cholesterol)

Question 3. Which country has the highest level of weight bias?

  1. Australia
  2. Canada
  3. Iceland
  4. United States
  5. All countries have similar levels of weight bias

Have You Been the Perpetrator or the Recipient of Weight Bias?

Let’s take a moment to look back at your life. In your lifetime, have you ever discriminated against an individual because they had overweight or obesity? If you didn’t explicitly discriminate, did you pass judgement about an individual and their weight status? Or, maybe you are an individual who was the recipient of such bias? Have you been made to feel unwelcome due to your weight? How did that make you feel? After reading the aforementioned questions, it is likely that you have either been the perpetrator or the recipient of weight bias. We should make strides to reduce weight bias because it leads to a worse quality of life for the recipients of such bias. I am frequently asked, “Doc, but isn’t it often just fun and games? I really don’t mean any harm by making fun of people who are just ‘fat.’” Well, it might not seem harmful to you, but for the person who experiences such bias it can have a life-long impact.

Is There a Relationship Between Weight Bias and Poor Education About Obesity?

One of the primary reasons that weight bias and stigma continue to be so pervasive in our society is because of inadequate knowledge about obesity. Despite the belief that weight regulation is all about “calories in and calories out,” we know that weight regulation is much more complex; this explains why some people gain and retain weight quite easily, whereas others have difficulty in gaining weight. There are a variety of contributing factors to obesity that are both internal and external to an individual (see Figure 16-1).

As noted in Table 16-1, contributors to obesity can be characterized in several ways; these conditions affect how a much a person eats and how many calories they can burn.

What Are the Common Forms of Bias in the United States?

The two most common forms of bias in the United States are race bias and weight bias. An article in the Washington Post noted that searches for “three black teenagers” on the most popular search engine, Google, were met with stereotyped pictures of black teenage males—mugshots (Guarino, 2016). When a similar search was conducted with the search terms of “three white teenagers,” the search returned pictures of smiling white teenagers. Similarly, in a Glamour magazine article, readers were shown pictures of two blond White women; one had a thin body type and the other had a heavy body type (Driesbach, 2012). The adjectives used to describe the thin woman were superficial, ambitious, confident, vain, conceited, and mean, whereas the adjectives used to describe the woman with the heavier body type were lazy, insecure, undisciplined, passive, and careless.

In a study that evaluated the differences among Black, Hispanic, and White women in the United States to ascertain the likelihood of explicit and implicit weight bias, Black women had less explicit weight bias than did White women (Hubner et al, 2016). Despite having lower levels of explicit weight bias, they had high levels of implicit weight bias that was strongly associated with their ethnic identity. Black women with a lower ethnic identity were more likely to have negative implicit bias than were those who had a stronger ethnic identity. These are examples of how bias appears in our society.

How Early in Life Does Weight Bias Develop (and Why)?

A recent study sought to determine how early in life children begin to demonstrate weight bias and how this is influenced by their mother’s own bias against individuals with excess weight. In this study, 70 mother–infant pairs were examined to determine their preference for a normal or heavy body type by allowing the infants and toddlers to view, in random order, pairs of individuals with normal weight status or overweight or obesity in which their viewing time (preferential viewing time) was measured (Spiel et al, 2016). Older infants (average age, approximately 11 months) displayed a preference for individuals with obesity, whereas older toddlers (average age, 32 months) displayed a preference for individuals with normal weight status. The bias against individuals with overweight and obesity was strongly related to their mother’s weight bias, such that the infants and toddlers with mothers with a strong bias against people with overweight and obesity had a much higher likelihood of having a similar bias.

How Does Paternal Influence Affect Weight Bias in Children?

Weight bias in mothers strongly influences weight bias in toddlers. However, do we know how parental weight bias influences preschool-aged children? One study evaluated more than 270 children (3-year-olds) and their parents to determine whether the parents’ beliefs about body size and dieting influenced their children over the course of 1 year (Tanneberger & Ciupitu-Plath, 2016); the children had more negative associations about larger body types. Fathers had a strong influence on their boys and their weight bias, whereas there was not a strong association with either parents’ beliefs and their daughter’s likelihood of having weight bias.

Is There a Relationship Among Weight Bias, Teasing, and Psychosocial Functioning?

A study of 1,047 boys between the ages of 7 and 11 in Germany sought to determine how a boy’s weight status (as defined by their body mass index [BMI]) at the start of the study influenced weight bias and teasing later in life (Alberga et al, 2017). They found that boys who had weighed more were more likely to have experienced weight teasing, weight-bias internalization, and restrained their eating. If a boy was teased about his weight, he was more likely to have emotional and conduct problems. For those boys who internalized the weight bias they experienced, they were more likely to have emotional problems and restrained eating. This study demonstrated that a boy’s weight status and the bias that they were subjected to affected their psychosocial heath.

What Is the Relationship Among Weight Bias Internalization, Metabolic Syndrome, and Mental Health?

A recent study sought to determine whether weight bias internalization was associated with the likelihood of having metabolic syndrome (a predisposition to developing type 2 diabetes mellitus) (Rudolph and Hilbert, 2017). In this study of 178 obese adults in a weight-loss trial, investigators measured blood pressure, waist circumference, fasting blood sugar levels (glucose), triglyceride levels (one of the bad cholesterols), and high-density lipoprotein (HDL) cholesterol levels (the good cholesterol). The study concluded that people who had higher levels of weight bias internalization had a greater likelihood of developing metabolic syndrome and high triglyceride levels. Additionally, persons who experienced weight bias developed stress that was a contributor to weight gain as well as disordered and maladaptive behaviors.

How Do Weight Stigma, Internalization, and Coping Strategies Relate to One Another?

In this module, we have already learned that weight bias and stigma is associated with obesity and its co-morbidities as well as negative health outcomes that further worsen the weight and health of individuals who have excess weight. It must also be noted that women and minority populations have higher rates of obesity in the United States. Despite the higher rates of obesity in these communities, little research has been done to explore obesity’s relationship to weight bias and stigma. In a study of 2,378 individuals, women were more likely to have weight bias internalization as men (Himmelstein et al, 2017). Black men and women were less likely to internalize weight bias than were White men and women. Black women were least likely (when compared to White women and Hispanic women) to cope with weight stigma with disordered eating, in contrast to Hispanic women, who were most likely to demonstrate signs of disordered eating when they internalized weight bias. Surprisingly, Black men were more likely to cope with weight stigma with eating. This study demonstrated that weight bias and stigma are present in racial groups, and racial and gender groups differ regarding how they cope with weight stigma.

Do Health Professionals Experience, Convey, or Manifest Weight Bias?

Perhaps one might think that medical students would have a low likelihood of demonstrating weight bias compared to those in the general population; however, this is far from true. A study conducted at Wake Forest Medical School tested third-year medical students with the Weight Implicit Association Test (IAT) and found that more than one-third of the students demonstrated a strong bias toward persons who carried excess weight, and that more than two- thirds of the students were unaware of their biases (demonstrating a high level of implicit bias) (Pantenburg et al, 2013). A more extensive study evaluated 1,795 medical students from 49 medical schools in the United States to determine how weight bias evolved between their first and fourth years of medical school (Puhl et al, 2015). They also compared the outcomes to those of nearly 400,000 (397,600) persons in the general public who visited www.projectimplicit.org between 2010 and 2013. The investigators measured implicit weight bias with the IAT. Although implicit weight bias decreased dramatically during medical school training, investigators found that explicit weight bias increased and paralleled the increase in explicit weight bias in the public. The authors of the study concluded that medical schools might reduce students’ weight biases by doing the following:

  • Increasing positive contact between students and patients with obesity
  • Eliminating unprofessional role-modeling by faculty members and residents
  • Altering curricula that focused on treating difficult patients.

In an in-depth evaluation of implicit weight bias in medical students, using Implicit Relational Assessment Procedure (IRAP) assessments, comparisons were made between first- and third-year medical students. Of the 325 assessments, 40 were completed by the same group of medical students in their first and third years of medical school. There was little change in implicit attitudes toward individuals classified as overweight, but there was a significant improvement in implicit bias toward persons with obesity. In the group of 40 students who were followed from their first to third years of medical school, there was a substantial improvement in bias toward persons classified as overweight, but there was not a significant improvement in weight bias with respect to bias toward patients with obesity.

In a recent review of the medical literature to determine whether there were any consistently used strategies to reduce weight bias in health professionals (Baker et al, 2016), researchers found that bias was reduced in weight professionals with enhanced knowledge of the causes of obesity; however, there was no evidence to support long-term benefits of having this knowledge.

When individuals are obese they often recognize that health providers have a bias against them, and they receive threatening environmental cues within the health-care setting; these align with health-care provider’s bias (Phelan et al, 2015). As a result of such weight bias, patients will avoid care, mistrust health providers, demonstrate poor adherence with recommendations, become stressed, and have poor patient–provider interactions.

In concert with the health provider’s stereotypes of the patient and biased decision making, these attitudes lead to negative patient outcomes.

What Is the Relationship Between Weight Stigma and Health Outcomes?

Weight stigma leads to stress, and stress affects eating and physical activity (e.g., binge eating, increased caloric consumption, maladaptive weight control, disordered eating, motivation for physical activity, and physical activity) and physiologic reactivity (e.g., increased levels of C-reactive protein [an inflammatory marker in the blood], cortisol [a stress hormone], A1C levels [hemoglobin A1C which conveys the average blood sugar over the prior 3-month period], elevated blood pressure) (Allison et al, 2016). Weight stigma also affects the delivery of health services (e.g., poor patient adherence, less trust of health providers, avoidance of follow-up care, delay in preventive health screenings, poor communication). The negative impact on eating and health behaviors, physiologic reactivity, and health-care services leads to further weight gain that causes impaired psychological health and distress (e.g., depression, anxiety, low self-esteem, poor body image, substance abuse, suicidal ideation) as well as physiological health and distress (e.g., poor blood sugar control, less effective chronic disease self-management, more advanced and poorly controlled chronic disease, lower health-related quality of life).

How Can Exercise Be Promoted Without Promoting Weight Bias?

Although health education campaigns aim to prevent and reduce obesity, they often contain weight-stigmatizing visual content that often leads to unintended negative health consequences (Phelan et al, 2015). In a quest to identify non- stigmatizing visual content investigators used an on-line sample of 483 women who viewed several scenarios: a woman with obesity portrayed stereotypically (e.g., eating pizza); a woman with obesity exercising (a counter-stereotypical portrayal); a woman with obesity portrayed neutrally; or a lean woman exercising. Persons with obesity who viewed the portrayal in a neutral way were less likely to elicit expressions of weight bias attitudes and to have higher reports of exercise-liking/comfort. Among persons of normal weight, images portraying women with obesity in a stereotypical or counter-stereotypical fashion increased the likelihood of negative stereotypes as compared to lean images. The study concluded that neutral portrayals of individuals might be an effective route to promote exercise without perpetuating stigma.

Is There a Relationship Among Weight Bias, Educational Opportunities, and Employability?

In a study of students applying for graduate-level psychology programs, a higher BMI significantly predicted fewer post-interview offers of admission into psychology graduate programs; this relationship was stronger for female applicants (Carels et al, 2013). The BMI was not related to the overall quality or the number of stereotypically weight-related adjectives in letters of recommendation, but a higher BMI was related to more positive adjectives in letters.

In a recent study published in Obesity Surgery, 154 participants viewed an image of a normal-weight woman and rated their impression of her (Durso et al, 2015). They then rated their impression of her image with excess weight after learning how she had previously gained and subsequently lost weight. Participants rated the individual less favorably (e.g., perceived employability if they thought the individual who once carried excess weight lost weight through surgery versus diet and exercise).

What Is the Impact of Reality TV Shows and Weight Bias?

In a study in Obesity, 59 participants were assigned to an experimental group (i.e., they viewed one episode of The Biggest Loser) or a control group (i.e., they viewed one episode of a nature reality show) (Gujral et al, 2012). The levels of weight bias of the study participants were measured by the IAT, the Obese Person Trait Survey (OPTS), and the Anti-fat Attitudes scale (AFA) at baseline and one week after viewing the episodes. Participants in the experimental group had significantly higher levels of dislike of individuals with overweight and obesity and more strongly believed that weight was within one’s control after the experiment.

Is There a Relationship Between Weight Bias and Stigma in the United States and Abroad?

In an assessment of countries and their weight bias and stigma, investigators studied bias in Australia, Canada, Iceland, and the United States (Raves et al, 2005). The extent of weight bias was consistent across all four countries. Attributions of behavioral causes of obesity and beliefs that obesity is attributable to a lack of willpower and personal responsibility lead to stronger bias. The magnitude of weight bias was stronger among men and among individuals without family or friends who had experienced this form of bias.

Are there Laws Against Obesity Discrimination?

Weight discrimination is prevalent, and the need for anti-discrimination legislation rises with more pervasive practices of discrimination. Public support of weight-related anti-discrimination laws or policies in Germany, Iceland, and the United States has been studied (Paxton and Damiano, 2017). Questionnaires were administered to ascertain public support for general and employment- specific weight-related anti-discrimination policies, weight-based victimization, and weight-bias internalization. Although more than half of the German sample agreed with anti-discrimination policies, general anti-discrimination laws received lower support than did employment-specific laws. Support for policies considering obesity as a physical disability was greatest in Germany, whereas support for employment-specific anti-discrimination laws was lower in Germany than in the United States and in Iceland. Total support for weight-related anti- discrimination policies was predicted by lower age, female gender, overweight or obese status, residence in Germany, church membership, and readiness to vote in elections.

Conclusions

  • Weight stigma has a negative impact on the health and psychological health of patients who struggle with obesity.
  • Weight bias develops in infancy.
  • Maternal and paternal anti-fat bias influences children.
  • Weight bias can be mitigated by proper training of health professionals.
  • Efforts to reduce weight bias can improve the health and quality of life of those who struggle with overweight and obesity.

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