A Focus on Obesity, Part 2:
••Summer 2003/Vol. 7, No. 3

Health Systems

Kelly Brownell, PhD, and Rebecca Puhl on bias against obese people
Stigma and Discrimination in Weight Management and Obesity | pdf >>
By Kelly D Brownell, PhD; Rebecca Puhl

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 study¹ 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^2-6 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.⁷ 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^8-11 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.⁸

A survey of more than 1200 physicians assessed attitudes, interventions, and referral practices for obese patients.⁹ 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.⁹

Another study¹⁰ 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.¹⁰

Finally, a survey of the attitudes and practices of 752 general practitioners in weight management reported mixed results.¹¹ 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.¹¹

Negative attitudes in physicians may lead obese persons to avoid seeking health care. In one study,¹² 290 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 were significantly less likely to report receiving annual pelvic exams.¹²

Among physicians, 17% reported reluctance to provide pelvic exams to very obese women, and 83% indicated reluctance to provide a pelvic exam if the patient herself was hesitant.¹² Given that overweight women may hesitate to obtain exams and that physicians are reluctant to perform exams on obese or reluctant women, many overweight women may not receive necessary preventive care.

Two other studies^13,14 also documented delays in seeking medical care by obese women. One study¹³ found a significant relation between body mass index (BMI) and appointment cancellation. More than 12% of women indicated they delayed or canceled physician appointments because of weight concerns. In addition, 32% of women with BMI over 27 and 55% of women with BMI over 35 delayed or canceled visits because they knew they would be weighed. The most common reason for delaying appointments was embarrassment about weight.¹³

A study of nearly 7000 women,¹⁴ included in the National Health Interview Survey for 1992, found that increased BMI was associated with both increased physician visits and decreased preventive health care services. Obese women were significantly more likely than non-obese women to delay breast and gynecologic exams and Pap tests, despite more frequent visits.¹⁴

It is important to note that the stigma of obesity is somewhat unique from that of other marginalized groups, in that obese people internalize societal anti-fat and pro-thin biases. Obese people agree with society's assessment that an imperfect body represents an imperfect person.

Obese people attempt to cope with stigma through one or more variably effective and adaptive means, including confirming negative societal stereotypes, providing socially acceptable explanations for excess weight, confrontation, social activism, avoidance, compensation, and losing weight through medical or surgical treatments.¹⁵

Self-report studies show substantial changes in perceived discrimination after bariatric surgery. In one,¹⁶ 87% of presurgical patients reported that their weight prevented them from being hired for a job, 90% reported being stigmatized by coworkers, 84% avoided being in public places because of their weight, and 77% reported daily depression. Fourteen months after surgery, every patient reported reduced discrimination, most reported rarely or never perceiving prejudice after surgery, and 90% reported substantially increased cheerfulness and confidence.¹⁶ Studies are limited by self-reports and self-selected samples, but it is important to consider the influence of social perceptions in motivating the decision to undergo surgery.

Efforts to reduce bias toward obese people have been limited. One intervention study¹⁷ attempted to reduce stigma toward obese patients among medical students. Before random assignment to a control group or an education intervention using videos, written materials, and role-playing exercises, the majority of medical students in the study characterized obese individuals as lazy, sloppy, and lacking in self-control, despite the students indicating that they had an accurate understanding of obesity's cause. After the intervention, students demonstrated significantly improved attitudes and beliefs about obesity compared with the control group. One year later, the effectiveness of the intervention was still evident.¹⁷

Other studies to assess strategies for reducing implicit bias against obese people in the general population have been reported.¹⁸ Using the IAT, strong anti-fat implicit attitudes and stereotypes were demonstrated before any intervention but no anti-fat bias was seen. Participants of normal and excess weight were assigned to one of three groups: no intervention, reading a "news story" identifying the cause of obesity as genetic, or reading a similar story reporting the cause of obesity as overeating and lack of exercise.

Other subjects were asked to read one of three stories: a neutral story, a story about discrimination experienced by an individual with a physical handicap, or one about discrimination experienced by an obese person.¹⁸

The pattern of results was somewhat surprising. The group that received information that indicated obesity was predominantly caused by behavioral factors (such as overeating and lack of exercise) had higher anti-fat bias compared with that of other groups; the group that received information that indicated obesity was mainly due to genetics did not have lower implicit or explicit bias. Similarly, attempts to evoke empathy through stories of discrimination against an overweight young woman did not produce lower bias across the whole sample.¹⁸

However, in two studies, the interventions did lead to lower implicit bias for overweight participants. Given that obese individuals internalize society's bias, this may have interesting implications.¹⁸

Awareness training is important in helping health care professionals recognize that the societal anti-fat bias is shared by everyone, including them. We must pay attention to specific ways bias manifests, including subtle ways such as waiting room chairs and treatment gowns that aren't large enough or care providers who have negative, callous, or ambivalent attitudes. As a society, our goal must be to provide the same level of care for overweight people that others receive. To do so, we must also be attentive to the special needs of this population; obese individuals may be more reluctant to come in for preventive care, such as mammograms, because they're afraid of being weighed and criticized. The health care system must go out of its way to address these issues and encourage people to get the care they need and deserve.

References

1. Puhl R, Brownell KD. Bias, discrimination, and obesity. Obes Res 2001 Dec;9(12):788-805.
2. Price JH, Desmond SM, Krol RA, Snyder FF, O'Connell JK. Family practice physicians' beliefs, attitudes, and practices regarding obesity. Am J Prev Med 1987 Nov-Dec;3(6):339­45.
3. Hoppe R, Ogden J. Practice nurses' beliefs about obesity and weight related interventions in primary care. Int J Obes Relat Metab Disord. 1997 Feb;21(2):141­6.
4. Maroney D, Golub S. Nurses' attitudes toward obese persons and certain ethnic groups. Percept Mot Skills 1992 Oct;75(2):387­91.
5. Oberrieder H, Walker R, Monroe D, Adeyanju M. Attitudes of dietetics students and registered dietitians toward obesity. J Am Diet Assoc 1995 Aug;95(8):914­6.
6. Blumberg P, Mellis LP. Medical students' attitudes toward the obese and morbidly obese. Int J Eating Disord 1985;4(2):169-75.
7. Teachman BA, Brownell KD. Implicit anti-fat bias among health professionals: is anyone immune? Int J Obes Relat Metab Disord 2001 Oct;25(10):1525-31
8. Young LM, Powell B. The effects of obesity on the clinical judgments of mental health professionals. J Health Soc Behav 1985 Sep;26(3):233­46.
9. Kristeller JL, Hoerr RA. Physician attitudes toward managing obesity: differences among six specialty groups. Prev Med 1997 Jul-Aug;26(4):542­9.
10. Pratt CA, Nosiri UI, Pratt CB. Michigan physicians' perceptions of their role in managing obesity. Percept Mot Skills 1997 Jun;84(3 Pt 1):848­50.
11. Campbell K, Engel H, Timperio A, Cooper C, Crawford D. Obesity management: Australian general practitioners' attitudes and practices. Obes Res 2000 Sep;8(6):459­66.
12. Adams CH, Smith NJ, Wilbur DC, Grady KE. The relationship of obesity to the frequency of pelvic examinations: do physician and patient attitudes make a difference? Women Health 1993;20(2):45-57.
13. Olson CL, Schumaker HD, Yawn BP. Overweight women delay medical care. Arch Fam Med 1994 Oct;3(10):888­92.
14. Fontaine KR, Faith MS, Allison DB, Cheskin LJ. Body weight and health care among women in the general population. Arch Fam Med 1998 Jul-Aug;7(4):381­4.
15. Puhl, R, Brownell, KD. Ways of Coping with Obesity Stigma: review and conceptual analysis. Eating Behaviors 2003;4:53-78.
16. Rand CS, Macgregor AM. Morbidly obese patients' perceptions of social discrimination before and after surgery for obesity. South Med J 1990 Dec;83(12):1390-5.
17. Wiese HJ, Wilson JF, Jones RA, Neises M. Obesity stigma reduction in medical students. Int J Obes Relat Metab Disord 1992 Nov;16(11):859­68.
18. Teachman BA, Gapinski KD, Brownell KD, Rawlins M. Jeyaram S. Demonstrations of implicit anti-fat bias: the impact of providing causal information and evoking empathy. Health Psychol 2003 Jan;22(1):68-78.

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