Physicians Not Immune From Anti-Fat Bias: A Newsmaker Interview With Marlene Schwartz, PhD

Laurie Barclay, MD

October 01, 2003

Sept. 30, 2003 — Editor's Note: Even health professionals specializing in obesity tend to be biased against overweight individuals, according to the results of a study published in the September issue of Obesity Research . Although the level of bias is lower than in the general community, it is striking in a group trained in the genetic and environmental basis of obesity.

In this study, 389 health professionals attending an international obesity conference in Quebec City completed the Implicit Associations Test and a self-administered questionnaire measuring explicit attitudes, personal experiences with obesity, and demographic characteristics. These clinicians and researchers associated the stereotypes lazy, stupid, and worthless with obese people. Bias was less in older individuals, in men, in those working directly with obese patients, in those who felt they understood the experience of obesity, and in those who had obese friends.

To learn more about the implications of these findings, Medscape's Laurie Barclay interviewed lead author Marlene Schwartz, PhD, coordinator of the Yale Center for Eating and Weight Disorders and an associate research scientist in psychology at Yale University in New Haven, Connecticut. The study was funded by the Rudd Institute, a nonprofit foundation studying anti-fat bias. Dr. Schwartz has no other financial disclosures.

Medscape: What are the main study findings?

Dr. Schwartz: The primary findings of the study are that health professionals who specialize in obesity exhibit an automatic anti-fat bias. The level of this bias is lower than [that] found in previous research with community samples; however, it is still significant.

Medscape: Is there any explanation for the findings that younger people show greater bias than older people, or that men tend to be less biased than women?

Dr. Schwartz: My hypothesis is that these findings are consistent with research that young women are the group at highest risk for body dissatisfaction. This is probably due to the fact that young women are also exposed to the greatest societal pressures to be thin, such as viewing fashion models or TV characters.

Medscape: Were you surprised that health professionals tended to show the same bias as lay persons? What can be done to counteract this bias?

Dr. Schwartz: The health professionals in our study were less biased than lay persons, which was encouraging, but the fact that they did have the bias did not surprise us. We all have grown up in the same society and are exposed to the same media messages and societal pressures to be thin. The fact that even health professionals have the bias reinforces how incredibly pervasive and powerful the stigma of obesity is in our society.

Medscape: If understanding the experience of obesity and having obese friends tends to lessen bias, does this suggest that sensitivity training might be helpful?

Dr. Schwartz: Thank you for asking this question — the purpose of this study was not to simply say that professionals are biased; it is to move the field forward in finding ways to combat this bias. In fact, the North American Association for the Study of Obesity is the group that we studied, and it was their journal where the study was published. This group is courageous in acknowledging this bias and wants to be in the forefront of making changes to promote positive attitudes toward obese individuals.

So, yes, sensitivity training might be helpful. Trying to understand the experience of an obese person — for example, by wearing a "fat suit" for a day — might help. I think that one way to change our thinking is to substitute another physical condition or medical problem for obesity when we think about what is appropriate. For example, in professional presentations, it is not uncommon for researchers to have unflattering pictures of obese people eating large amounts of food, or wearing clothes that are too tight, to illustrate their talk and be humorous. I've often thought that if we were at an AIDS conference it would never be tolerated to have pictures of emaciated people using intraveous drugs or having unprotected sex as a way to illustrate talks.

The researchers associated with the Rudd Institute have been doing a number of studies to test different ways to change levels of bias, and we haven't yet found a solution. Ongoing research by Rebecca Puhl suggests that people are most likely to change their attitudes when they find out that others they respect do not hold those attitudes. In other words, knowing that anti-fat attitudes are not tolerated among respected groups may help people change their own attitudes.

Medscape: Could some of the negative stereotypes endorsed by physicians in this study, such as linking "obese people" to "bad," be explained by the negative health consequences of obesity?

Dr. Schwartz: This is an excellent question as well. Yes, some people say that they associate "fat people" with "bad" because it is bad to be fat; it's unhealthy in a number of ways. It is possible that this accounts for some of the effect, and that the positive versus negative valence of the adjective pairs was responsible for the effect more than the actual words themselves. However, I think about the research on anti-fat attitudes among young children (a study was published earlier this year by Latner & Stunkard in Obesity Research on this) and I'd be willing to bet anything that elementary school children do not discriminate against their overweight peers because they are thinking about their increased risk of heart disease and diabetes.

Medscape: Does weight bias among health professionals endanger obese patients or increase the risk of less-than-optimal care?

Dr. Schwartz: This is an important question to study. We do not know the relationship between implicit attitudes and actual behavior around patients, but we hypothesize that our attitudes do affect care. Our hope is that increasing awareness will help all of us be more mindful of the assumptions we make about our patients — such as whether or not we believe they will be compliant, or whether we believe they are doing all they can to take care of themselves — are influenced by their size.

As a psychologist, I have worked with patients who have made tremendous behavior changes in terms of exercise and healthy eating and haven't lost as much weight as their physicians expected. My patients felt their physicians didn't believe how hard they'd worked or didn't value the changes they'd made as much as the number on the scale. My message to physicians is to focus on the behaviors of their patients more than the number on the scale. We are all limited in how much absolute control we have over what that number will be.

Medscape: Is there anything you'd like to add in closing?

Dr. Schwartz: We have put the Implicit Association Test on the Web, and it would be great if you could encourage your readers to take the test themselves. It takes about 20 minutes and is at This site links to [the Rudd Institute Web site], which describes the organization that funded this study and is committed to addressing obesity bias in our culture.

What makes me panic about this study is that demonstrating anti-fat attitudes in health professionals specializing in obesity might legitimize these attitudes in the general population. These findings should not be used to justify anti-fat bias, but rather to point out that even physicians and other providers need to be aware of their own bias and take measures to counteract it.

Obes Res. 2003;11:1033-1039

Reviewed by Gary D. Vogin, MD


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