Social stigma of obesity

The social stigma of obesity or fatphobia has caused difficulties and disadvantages for overweight and obese people. Weight stigma is similar and has been broadly defined as bias or discriminatory behaviors targeted at individuals because of their weight.[1][2] Such social stigmas can span one's entire life, as long as excess weight is present, starting from a young age and lasting into adulthood.[3] Several studies from across the world (e.g., United States, University of Marburg, University of Leipzig) indicate overweight and obese individuals experience higher levels of stigma relative to their thinner counterparts. In addition, they marry less often, experience fewer educational and career opportunities, and on average earn a lesser income than normal weight individuals.[3] Although public support regarding disability services, civil rights and anti-workplace discrimination laws for obese individuals have gained support across the years,[3] overweight and obese individuals still experience discrimination, which may have implications to physiological and psychological health. These issues are compounded with the significant negative physiological effects associated with obesity.[4]

Anti-fat bias refers to the prejudicial assumption of personality characteristics based on an assessment of a person as being overweight or obese. It is also known as "fat shaming". Fat activists allege anti-fat bias can be found in many facets of society,[5] and blame the media for the pervasiveness of this phenomenon.[6][7]

Prevalence

Research indicates that self-reported incidents of weight-based discrimination have increased in the last few decades.[8] Individuals who are subjected to weight-related stigma appear to be rated more negatively when compared with other groups, such as sexual minorities, and those with mental illness.[9]

Anti-fat bias has been observed in groups hoping to become physical education instructors. In one study, a group of 344 psychology or physical education majors at a New Zealand University were compared, and it was found that the prospective physical education teachers were more likely to display implicit anti-fat attitudes than the psychology majors.[10]

A number of studies have found that health care providers frequently have explicit and/or implicit biases against overweight people, and it has been found that overweight patients may receive lower quality care as a result of their weight.[11] Medical professionals who specialize in the treatment of obesity have been found to have strong negative associations toward obese individuals.[12]

In one study, preschool-aged children reported a preference for average-sized children over overweight children as friends.[13] As a consequence of anti-fat bias, overweight individuals often find themselves suffering repercussions in many facets of society, including legal and employment issues later in their life.[5] Overweight individuals also find themselves facing issues caused by increased weight such as decreased lifespan, joint problems, and shortness of breath.[14]

According to a 2010 review of published studies, interventions seeking to reduce prejudice and social stigma against fat and obesity are largely ineffective.[15]

Characteristics

Weight-related stigma can be characterized by the following aspects:

1. An individual does not have to be overweight or obese to experience weight-related stigma.[16]
2. Studies have indicated that experiencing weight stigma may perpetuate the associated behaviors. This suggests that being subjected to weight-related stigma, may exacerbate the targeted condition.
3. Many groups who are subjected to stigmatisation tend to be minorities. Overweight and obese individuals make up the majority of the population in the United States and in other parts of the world.[17]
4. Individuals who are overweight or obese tend to devalue their own in-group and prefer the out-group (i.e. thinner individuals).[18]

Theoretical explanations

In order to understand weight-biased attitudes, theories have been proposed to explain the discrimination. Christian S. Crandall discusses the "Justification of Stigmatization".[19] Also in his Social Ideology Perspective draws on traditional North American values of self-determination, individualism and self-discipline. Based on these values, anti-fat attitudes may derive from directing blame towards individuals who are overweight.[20] Similarly, the attribution theory suggests that attitudes towards obese individuals are dependent on how much control they are perceived to have over their weight.[2] Throughout the literature, numerous studies have shown support for this theory. One study conducted a multinational examination of weight bias across four countries (Canada, United States, Iceland, and Australia) with comparable obesity rates.[21] The study found that attributions of behavioral causes of obesity were associated with greater weight bias. Further, these individuals were more likely to view obesity as being due to a lack of willpower. There appears to be decreased weight bias when weight was attributed to factors that were less within the individual's control, or when individuals are perceived as trying to lose weight.[22]

Trait attribution

Anti-fat bias leads people to associate individuals who are overweight or obese with negative personality traits such as "lazy", "gluttonous", "stupid", "smelly", "slow", or "unmotivated". This bias is not restricted to clinically obese individuals, but also encompasses those whose body shape is in some way found unacceptable according to society's modern standards (although still within the normal or overweight BMI range).[23] It is a classical example of the halo effect in cultures where physical preferences favor low body fat. Fat-shaming is fairly common in the United States, even though most adult Americans are overweight. Huffington Post wrote "two-thirds of American adults are overweight or obese. Yet overweight and obese individuals are subject to discrimination from employers, healthcare professionals and potential romantic partners".[24]

Anti-fat bias can be moderated by giving a mitigating context to the individual's appearance of obesity.[25] For example, when told an individual was obese because of "overeating" and "lack of exercise", a higher implicit bias was found among study participants than those not provided with context. When the group was told that "genetics" was to blame, they did not exhibit a lowered implicit bias after the explanation.

Anti-fat bias is not a strictly Western cultural phenomenon. Instances of implicit anti-fat bias have been found across several cultures.[26]

Newer research suggests that the stereotypical traits and attributions are post hoc justifications for the expression of prejudice against obese people. That is, a person first experiences involuntary feelings of disgust and aversion when seeing an obese person, and then the person tries to figure out a "rational" reason for these feelings. The person attributes negative characteristics, such as deciding that obese people are lazy or ignorant, to justify or explain the negative feelings.

Additionally, recent work around physical appearance issues, body image, and anti-fat or obesity prejudice suggests that feelings about one's own appearance may stimulate downward physical comparisons with obese individuals in order to make one feel better about one's own physical appearance.[27][28]

Weight discrimination

Weight stigma is present in multiple settings including healthcare, education, interpersonal situations, multiple media forms and outlets, and across many levels of employment.[2]

In the media

Media, in general, underrepresents overweight individuals and when these roles are present, they are often minor, stereotyped roles. They are more commonly seen eating, and are less likely to be involved in a romantic relationship compared to the average weight television character.[2] The media is often blamed for the strong negative trait associations that society has toward overweight individuals. There is a great deal of empirical research to support the idea of Thin Ideal media, or the idea that the media tends to glorify and focus on thin actors and actresses, models, and other public figures while avoiding the use of overweight individuals.

Representation of overweight individuals in prime time programming is not representative of the actual proportion in the population.[29] Only 14% of females and 24% of males featured in the top ten prime-time fictional programs of 2003 were overweight. Those that were shown had few romantic interactions, rarely shared affection with other characters, and were frequently shown consuming food.

In 2007, another analysis sampled 135 scenes featuring overweight individuals from popular television programs and movies and coded for anti-fat humor.[30] The majority of anti-fat humor found was verbal and directed at the individual in their presence.

Puhl et al. (2009) also reviewed how in entertainment, news reporting, and advertising, media is a particularly potent source of weight stigma. News reports have blamed individuals with overweight and obesity for various societal issues including prices of fuel, global temperature trends, and precipitating weight gain among their peers.[2] The literature also documents how in television programs, actors with overweight and obesity are often cast in minor roles, if at all. Programs also often depict them as the targets of teasing and derogation and often portray heavy characters displaying eating behaviors stereotypical to overweight and obesity.[2] This relatively low social status assigned to characters with overweight and obesity in television is also evidenced in children's television, a tendency that perpetuates antifat attitudes among viewers.[2] In terms of media attention for obesity itself, a recent review by Puhl and Suh (2015) revealed that obesity-related media campaigns that used stigmatizing messages, in fact, undermine motivations and intentions to pursue healthy eating and exercise behaviors.[31]

On September 29, 2011, prominent nationally syndicated columnist Michael Kinsley (founding editor of Slate magazine) wrote, "New Jersey Governor Chris Christie cannot be president: He is just too fat ... why should Christie's weight be more than we can bear in a president? Why should it even be a legitimate issue if he runs? One reason is that a presidential candidate should be judged on behavior and character ... Perhaps Christie is the one to help us get our national appetites under control. But it would help if he got his own under control first."[32] Governor Christie responded on October 4, 2011, stating "The people who pretend to be serious commentators who wrote about this are among the most ignorant I've ever heard in my life. To say that, because you’re overweight, you are therefore undisciplined—you know, I don't think undisciplined people get to achieve great positions in our society, so that kind of stuff is just ignorant."[33]

In 2013, Haley Morris-Cafiero's photography project "Wait Watchers", in which she photographed the reactions to her presence by random passers-by, went viral. New York magazine wrote, "The frequency with which Morris-Cafiero succeeds at documenting passersby's visible disdain for her body seems pretty depressing".[34]

There is also evidence that especially young adults and adolescents experience weight stigma on social media. For example, a study suggests that adolescent patients with obesity experience derogatory comments about weight and visual self-presentation in their online social networks. The study found that this was particularly evident among girls and that it not only referred to presenting their bodies but also included not wanting to present food items associated with obesity such as junk food.[35]

In education

In regards to more direct weight bias, obese individuals were 40-50% more likely to report major discrimination compared to those of average weight across a multitude of settings.[36] More specifically, studies have shown that those who are overweight face discrimination throughout the educational and employment systems. In the educational setting, those who are overweight as youth often face peer rejection[37] and have poorer school performance, if they experience weight-based teasing.[38] As individuals grow older they may be less likely to be admitted into a college compared to average weight persons, and in some cases, individuals were admitted to academic institutions and dismissed due to weight.[2][9] Research suggests that within the classroom teachers may perceive overweight individuals’ work more poorly compared to average weight individuals, and the attention the teacher provides to these two groups may differ.[2] Research has also found that overweight females receive less financial support for education from their families than average weight females, after controlling for ethnicity, family size, income, and education.[2][9]

Puhl and colleagues (2009) concluded from their review of weight stigma in education that this area still warrants further investigation, but that current trends indicate that students with overweight and obesity face barriers to educational success at every level of education.[2] Reviewed research demonstrates that educators, particularly Physical Education teachers, report antifat attitudes toward their students with overweight and obesity, which may undermine educational achievement.[2] Importantly, the education disparities for students with overweight and obesity appear to be strongest for students attending schools where obesity is not the norm. Several studies have evidenced that in environments such as these, students with overweight and obesity face greater educational disadvantages and are less likely to attend college, an effect that is particularly strong among women.[2] Moreover, weight stigma in educational settings also affects interpersonal relationships (see "Interpersonal situations" below).[31]

In employment

Studies suggest that obese individuals are less likely to be hired and once hired, have greater termination rates than average weight individuals.[2][9] Specifically, a national survey found that obese individuals were 26% more likely not to be hired, not receive a promotion, or to be fired compared to average weight persons.[36] Such outcomes may be a result of employers viewing them as less agreeable, less competent and lazier than average weight individuals.[2][9]

Weight stigma leads to difficulty obtaining a job, worse job placement, lower wages and compensation, unjustified denial of promotions, harsher discipline, unfair job termination, and commonplace derogatory jokes and comments from coworkers and supervisors.[2] In their review, Rebecca M. Puhl et al. find that employees with overweight and obesity report their weight as the most influential factor contributing to losing their job.[2] Another review by Giel and colleagues (2010) found that certain stereotypes about employees with overweight and obesity are highly endorsed by employers and supervisors, in particular that they have poorer job performance and that they lack interpersonal skills, motivation, and self-control.[39]

In politics

New Jersey Governor Chris Christie is a politician who may have suffered from weight-related discrimination at times during his political career.

A study by Michigan State University researchers shows evidence that overweight political candidates tend to receive fewer votes than their thinner opponents. The researchers analyzed data from the 2008 and 2012 U.S. Senate elections. Using a previously established scientific method, research assistants determined from color photos whether the candidates in 126 primary and general elections were of normal weight, overweight, or obese.

Both obese men and women were often less likely to get on the ballot in the first place. When it came to merely being overweight, women were seen underrepresented on the ballot, though men were not. This is consistent with previous research showing men who are slightly heavy tend not to experience the same discrimination as slightly overweight women.

However, when it came to the voting, both male and female candidates, whether obese or simply overweight, tend to get a lower share of the vote total than their more slender opponents. Some politicians have resorted to extreme weight loss measures, including surgery, to increase their elect-ability to political office. [40]

In healthcare

Medical professionals may be more likely to view obese individuals in negative terms such as weak willed, unsuccessful, hopeless, and non-compliant with their treatments. As such, these individuals may receive poorer care compared to average weight people. Doctors have reported less intervention and an avoidance of weight-related discussion with obese patients. Additionally, nurses have reported a reluctance to touch obese persons during treatment.[9] A national survey found that individuals who were overweight reported a three times higher likelihood to be denied medical care than average weight people.[36] Further, health professionals who specialize in obesity showed strong implicit and explicit anti-fat bias as measured by self-report and the Implicit Associations Test (IAT).[41] However, such biases were mixed amongst dietitians and nutritionists.[42]

In their 2009 review, Puhl and colleagues found that many studies provide evidence supporting the notion that health professionals (including doctors, nurses, medical students, fitness professional, and dietitians) consistently endorse negative stereotypes about patients with overweight and obesity, in particular ascribing to them culpability for their weight status.[2] Weight stigma in the healthcare settings leads to impaired patient-provider communication, poorer doctor-patient relationships, poorer medical care and treatment (for example doctors spending less time with patients), and avoidance of the healthcare system all together on the part of the patient.[2] However, it is important to point out that the evidence that has been reviewed thus far comes primarily from self-report studies. Therefore, Puhl and colleagues concluded that research examining actual health outcomes is needed.[2] Overall, the impact of weight stigma in healthcare has become so problematic that many scholars have suggested that obesity-prevention programs should make minimizing stigma a priority.[2][43]

Interpersonal situations

Although a less studied topic than employment and healthcare, several studies reviewed by Puhl and colleagues (2009) provide evidence that overweight and obese women in particular face weight stigma from many interpersonal sources including family, friends, and romantic partners.[2] Another recent review by Puhl and Suh (2015) also documented that in school settings weight-based bullying is one of the most prevalent types of harassment reported by parents, teachers, and students.[44] Experiencing interpersonal weight stigma is related to myriad negative physical and mental health consequences (see "Physical and Mental Health Consequences of Experiencing Weight Stigma" below).

In early development

This external stigmatization and its internalized effects have been examined across different age groups. Overweight and obese children and adolescents experience stigmatization from parents, teachers, and peers.[45] Peer stigmatization, especially, may be difficult for overweight adolescents considering the role of peer support in promoting identity development and self-esteem.[44] Some research suggests that negative attitudes about being overweight are even held by overweight and obese children themselves. Specifically, weight bias may become internalized and increases throughout childhood. It then decreases and levels-off during late adolescence and adulthood.[45]

Weight-based teasing in childhood and adolescence has been associated with a variety of damages to psychosocial health, including reduced self-esteem and lower self-concept,[45][46] higher rates of depression and anxiety disorders,[47][48][49] and even greater likelihood of entertaining suicidal thoughts.[45] Further, weight-based teasing has been associated with higher rates of binge eating and unhealthy weight control (e.g., fasting, self-induced vomiting, laxatives, diet pills, skipped meals and smoking).[45][50][51] Overweight adolescents who were bullied were also more likely to meet criteria for bulimia.[52]

A survey of 7,266 children aged 11 to 16 conducted by the World Health Organization reported higher rates of physical victimization (e.g., being shoved) with increasing body mass index among girls. Additionally, these results showed relational victimization (i.e., being excluded or having rumors spread about you) was reported more often at increasing body mass index by both girls and boys.[44] A separate survey of 7,825 students aged 11 to 17 also noted that, compared to average-weight peers, obese boys and overweight girls were more likely to be victims of bullying. Additionally, obese girls were more likely to be victims and perpetrators of bullying than their peers. Notably, overweight and obese adolescent girls also reported higher rates of smoking, drinking, and marijuana use relative to their normal-weight peers.[53]

Health-related outcomes associated with weight discrimination

In adulthood, individuals who experience weight discrimination are more likely to identify themselves as overweight regardless of their actual weight status.[54] The experience of weight stigma can function as motivation to avoid stigmatizing environments, and although it may motivate one to escape stigma through weight loss, it undermines one's capacity to do so.[55] Researchers have linked weight stigma to decreases in physical activity,[54][56][57] decreases in seeking health care[57] and increases in maladaptive eating patterns such as binge eating.[55][57] In addition, those who have experienced weight stigma have shown altered cardiovascular reactivity, increased cortisol level, oxidative stress, and inflammation.[55]

People who expect to be fat-shamed by healthcare providers are less likely to seek care for medical issues or for weight loss, even if the weight gain is caused by medical problems.[58] Common medical issues that cause weight gain include type 2 diabetes, polycystic ovarian syndrome, hypothyroidism, and the side effects of some medications.

In terms of psychological health, researchers found that obese individuals demonstrated a lower sense of well-being relative to non-obese individuals if they had perceived weight stigmatization even after controlling for other demographic factors such as age and sex.[59] Overweight and obese individuals report experiencing forms of internalized stigma such as body dissatisfaction as well as decreased social support and feelings of loneliness.[60][61] In addition, similar to findings in adolescence, weight stigma in adulthood is associated with lower self-esteem, higher rates of depression, anxiety, and substance abuse.[55][57][60]

In both adults and children with overweight and obesity, several reviews of the literature have found that across a variety of studies, there is a consistent relationship between experiencing weight stigma and many negative mental and physical health outcomes.[2][20][62][31][63] These will be discussed separately in the sections below, although physical and mental health consequences are often intertwined, in particular those related to eating disorders.

Papadopoulos and Brennan (2015) recently found that across many reviewed studies of weight loss treatment-seeking adults,[62] relationships emerged between experiencing weight stigma and both BMI and difficulty losing weight. However the findings are somewhat mixed. They also report evidence that experiencing weight stigma is related to poor medication adherence. Among weight loss treatment-seeking adults, experiencing weight stigma might exacerbate weight- and health-related quality of life issues.[62] This review along with reviews by Vartanian and Smyth (2013) and Puhl and Suh (2015) have also found that across several studies and in both adults and children, experiencing weight stigma is related to decreased exercise behavior overall, as well as decreased motivation to exercise, decreased exercise self-efficacy, and increased food craving and tendency to overeat.[20][62][44] It is important to note that these effects of weight stigma on exercise and physical activity emerge independent of Body Mass Index, suggesting that weight stigma becomes a unique barrier to physical activity outside of barriers that may be associated with overweight and obesity in particular. Finally, across many studies, Puhl and Suh (2015) also found that experiencing weight stigma is related to many physiological consequences as well, including increased blood pressure, augmented cortisol reactivity, elevated oxidative stress, impaired glycemic control/elevated HbA_1c, and increased systemic inflammation,[44][63] all of which have notable consequences for physical health and disease.

Mental health and psychological consequences

Broadly speaking, experiencing weight stigma is associated with psychological distress. There are many negative effects connected to anti-fat bias, the most prominent being that societal bias against fat is ineffective at treating obesity, and leads to long-lasting body image issues, eating disorders, suicide, and depression.[64]

Papadopoulos's 2015 review of the literature found that across several studies, this distress can manifest in anxiety, depression, lowered self-esteem, and substance use disorders, both in weight loss treatment-seeking individuals as well as community samples.[62] Many empirical reviews have found that weight stigma has clear consequences for individuals suffering from eating and weight disorders (including Anorexia Nervosa, Bulimia Nervosa, and Binge Eating Disorder), as it plays a unique role, over and above other risk factors, in perpetuating disordered eating psychopathology.[62][44][63] These results have emerged in both adult and adolescent, as well as in male and female samples. Notably, the studies included in these reviews reported their results emerging over and above the degree of overweight/obesity in their respective subjects, suggesting that weight stigma, in particular, and not just being overweight or obese, precipitates these negative outcomes.

One prominent argument against anti-fat bias is that it doesn't treat the underlying causes of obesity, especially the emotional issues faced by overweight children. Another argument is that you can't tell if someone has food addiction just by looking at them, as obesity is not the same thing as an eating disorder, and someone might be considered healthy even if they don't fit society's standards for what appears healthy. Fighters of anti-fat bias claim that health should not be connected to weight, as a person's weight isn't the only indicator of health. They also say that society promotes the opinion that fat bodies can't be attractive.[65][66]

Policy

Over the past few decades, many scholars have identified weight stigma as a long-standing form of social stigma and one of the last remaining socially acceptable forms of prejudice. It follows then that individuals who are targets because of overweight and obesity, still face uniquely socially acceptable discrimination.[67][68] Civil rights legislation such as Title VII of the Civil Rights Act of 1964 prohibits discrimination based on race and several other domains, but weight is not included in this act. At the local level, only one state in the US (Michigan) has policy in place for prohibiting weight-related employment discrimination and very few local municipalities have human rights ordinances in place to protect individuals of large body size.[2][69] Typically, the only type legislation that overweight and obese individuals can cite in lawsuits is related to disability. For example, the Americans with Disabilities Act is one such avenue, but as Puhl et al. (2009) report, it is difficult for many individuals with obesity to qualify as disabled according to the criteria included in this statute.[2]

Public health

Although many health policy scholars and public health initiatives have suggested that weight stigma might motivate weight loss, the evidence from the existing literature largely does not support this notion. As cited above, experiencing weight stigma (both interpersonally as well as exposure to stigmatizing media campaigns) is consistently related to a lack of motivation to exercise and a propensity to overeat.[20][62][44] In a 2010 review examining whether weight stigma is an appropriate public health tool for treating and preventing overweight and obesity, Puhl and Heuer concluded that stigmatizing individuals with overweight and obesity is detrimental in three important ways: (1) it threatens actual physical health, (2) it perpetuates health disparities, and (3) it actually undermines obesity treatment and intervention initiatives.[70] In line with this, another recent review of the consequences of experiencing weight stigma, this one conducted by Puhl and Suh (2015), concluded that considering the myriad negative physical and mental health consequences associated with experiencing weight stigma, it should be a target, instead of a tool, in obesity prevention and treatment.[44] These authors further recommend that a necessary first step in reducing weight stigma is raising broader awareness of its negative consequences.[44]

See also

• Fat acceptance movement
• Height discrimination
• Reddit anti-fat communities
• Sizeism

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