Stigma and Discrimination in Weight Management and Obesity

We have been studying bias and discrimination in obesity for four years and have found striking results. Clear discrimination against overweight people has been documented in three areas: education, health care, and employment. The reason for this appears to be very strong anti-fat attitudes. For example, 28% of teachers in one study said that becoming obese is the worst thing that can happen to a person; 24% of nurses said they are ‘repulsed’ by obese persons; and, controlling for income and grades, parents provide less college support for their overweight children than for their thin children. These attitudes can be studied explicitly or implicitly. Explicit attitudes are typically measured by paper and pencil surveys. Numerous studies document explicit negative attitudes about obesity among physicians, nurses, dieticians, and medical students. These attitudes include: obese people lack self-control and are lazy, obesity is caused by character flaws, and failure to lose weight is due only to noncompliance. Measuring implicit attitudes requires methods for studying attitudes that are beyond the subject’s awareness. The Implicit Associations Test (IAT) is a powerful way to identify prejudice with respect to race, gender, and other factors. Use of the IAT to study implicit anti-fat biases among health care professionals reveals a pervasive implicit bias against obesity, even among those who specialize in its treatment. Importantly, the evidence for implicit bias exists in the presence of only minimal evidence for explicit bias. That is societal anti-fat attitudes are so pervasive that even those who dedicate their lives to treating obesity aren’t immune from these attitudes despite wishing to avoid prejudice; these clinicians are not consciously aware of this bias. Several studies indicate that obesity may influence health care professionals’ judgments and practices. For instance, mental health workers evaluating a case history more frequently assigned negative symptoms to an obese patient than to overweight and average-weight clients and rated obese patients more severely in terms of psychological functioning. A survey of more than 1200 physicians assessed attitudes, interventions, and referral practices for obese patients. Although physicians recognized obesity’s health risks and perceived many patients as overweight, these physicians didn’t intervene as much as they should, were ambivalent about how to manage obese clients, and were unlikely to refer them to weight loss programs. Only 18% of physicians reported that they would discuss weight management with overweight patients, and 42% of physicians would have this discussion with mildly obese patients. Another study suggests that physicians may be ambivalent about treating obesity. Among a sample of 211 primary care physicians, only 33% reported feeling responsible for managing their patient’s obesity. They indicated that insufficient time, lack of medical training, and reimbursement issues made managing obesity difficult. Finally, a survey of the attitudes and practices of 752 general practitioners in weight management reported mixed results. These physicians reported positive views about their roles in obesity management. Unfortunately, they also underused practices which promote lifestyle changes in patients, described weight management as professionally unrewarding, and noted that they were commonly frustrated by what they perceived as poor patient compliance and motivation. Negative attitudes in physicians may lead obese persons to avoid seeking health care. In one study, 290 women and more than 1300 physicians anonymously responded to questionnaires about the influence of obesity on the frequency of pelvic examination. Among women, reluctance to undergo pelvic exams increased with weight, and very overweight women