Health Professional: Do You Have Hidden Weight Bias?

Rebecca M. Puhl, PhD

Disclosures

November 22, 2016

Editor's Note:
Health professionals may harbor hidden weight bias. Test yourself for weight bias that exists outside of your conscious awareness and control. What are your implicit attitudes about body weight? Do you have hidden weight bias? To find out, take the free Implicit Associations Test online at Harvard's Project Implicit website and then read our article to learn more about the harm caused by "fat shaming" in the healthcare system.

Fat Shaming in the Spotlight

The first presidential debate of 2016 triggered national conversations about trade, taxes, and cyberattacks in the United States. Unexpected, however, was the eruption of national discourse about fat shaming, which was ignited by a series of remarks made during the presidential debate, including a reference to a 400-pound computer hacker and criticism about the body weight and physical appearance of former beauty pageant winner Alicia Machado and celebrity Rosie O'Donnell. This segment of the presidential debate was one of the most replayed clips by national news outlets in the 24 hours after it aired on national television.[1]

Public fat shaming is a symptom of the broader and more systemic weight stigmatization and discrimination that exists in North America. Over five decades of research have documented weight-based shaming, bullying, stigmatization, and discrimination of children and adults who struggle with overweight and obesity.[2]Collectively, this research has documented the nature, extent, and impact of weight stigma, demonstrating persistent weight prejudice in multiple domains of living.

This evidence underscores inequities in employment, stigma from healthcare providers, bias from educators, rampant weight-based stereotypes in the media, and rejection and exclusion in interpersonal relationships.[2,3,4] Among adults in the United States, weight discrimination has become one of the most commonly reported types of discrimination,[5] and among youth, being overweight is now one of the most prevalent reasons for victimization and harassment at school.[6,7]

The Harms of Weight Discrimination

As advocacy organizations rally to bring increasing and needed attention to the social injustice of weight stigmatization, equally important is recognition in the medical field of its damaging impact on those who are targeted. Considerable evidence has documented adverse health consequences of fat shaming and stigma.

Individuals who experience weight stigma are vulnerable to psychological distress, including depression, anxiety, low self-esteem, poor body image, substance use, and suicidal thoughts and behaviors.[8,9] Perhaps less intuitive, but consistently demonstrated in studies, are increased risks for binge eating, unhealthy weight control behaviors, increased calorie intake, avoidance of physical activity, reduced motivation to diet, and elevated physiologic stress, all of which can reinforce obesity and weight gain.[10,11]

 
Fat shaming reduces quality of life and may inadvertently worsen weight-related health outcomes.
 

In fact, recent longitudinal studies with large, nationally representative samples of adults demonstrate that weight discrimination, but not other forms of discrimination, increase future odds of becoming and remaining obese over time.[12,13] Of additional concern is research demonstrating reduced quality and avoidance of healthcare owing to experiences of weight stigma from healthcare providers.[14]

Taken together, this evidence challenges and directly contradicts public perceptions that fat shaming will provide targeted individuals with incentive or motivation to lose weight. Instead, this stigma reduces quality of life and may inadvertently worsen weight-related health outcomes.

Stereotypes and Personal Blame

Despite the documented health consequences of weight stigma and attention to discriminatory practices against individuals with obesity, fat shaming continues. The persistence of societal stigma is partially attributable to ongoing public perceptions about the causes of, and solutions to, obesity, which often emphasize an individual-oriented locus of responsibility.[15,16]

Some of the most common weight-based stereotypes (eg, that people of higher body weight are lazy, gluttonous, or lacking in willpower and self-discipline) stem from inaccurate beliefs that body weight is infinitely malleable and within personal control. Not only do these stereotypes and causal attributions promote personal blame for obesity, but such assumptions disregard and oversimplify decades of substantial, sound science demonstrating the complexities of body weight regulation, including biological and genetic mechanisms that promote weight gain.[17,18]

Furthermore, shaming and blaming individuals for their body weight removes responsibility from the food industry and government to create an environment that supports and promotes weight-related health for the US public. Attributions of personal blame for body weight ignore powerful societal factors that have created the current obesogenic environment.

If fat shaming were an effective approach to provide incentive or motivation to lose weight, the majority of Americans wouldn't be struggling with overweight and obesity.

If fat shaming were an effective approach to provide incentive or motivation to lose weight, the majority of Americans wouldn't be struggling with overweight and obesity. Fat shaming is harmful, counterproductive, and ineffective, and it perpetuates societal prejudice and discrimination. It creates barriers to obesity prevention, intervention, and treatment and interferes with public health efforts to promote weight-related health.

The recent and highly visible examples of fat shaming that emerged in the presidential debate provide a national opportunity to raise awareness of this problem, but more important, they should serve as a call to action to identify and implement remedies for the two thirds of Americans whose body weight makes them vulnerable targets of public shame and unfair treatment.

Table. Test Yourself for Hidden Weight Bias

Fat shaming is often consciously and deliberately expressed. However, weight bias can be communicated in subtle ways as well. In fact, weight bias can be "implicit": that is, hidden bias that exists outside of our conscious awareness and control. Implicit weight bias is common among the general public and healthcare providers.

What are your implicit attitudes about body weight? Do you have hidden weight bias? To find out, take the free Implicit Associations Test online at Harvard's Project Implicit website.

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