THE STIGMA OF OBESITY

Content Warning: This article talks about the stigma of obesity and presents some of the research on negative effects of discrimination. Some of this article discuses body-shaming.

 

It turns out that the stigma of obesity and the related discrimination against overweight people may be causing more health problems than the actual excess weight.  In fact, the medical “dangers” of being overweight may be blown way out of proportion.

Research has shown that obese people experience discrimination in a variety of settings. This is often due to the misconception that obesity is a sign of laziness rather than a condition with complex causes that may be physical and/or psychological. Discrimination against obese people is one of the last socially acceptable prejudices in our society, and it runs so deep that obese individuals express an internalized stigma towards themselves, and towards other obese people (Crocker, Cromwell & Major, 1993).

Stigma and discrimination can cause profound harm to both mental and physical wellbeing. For overweight individuals in particular, being on the receiving end of discrimination may end up perpetuating the cycle of weight gain.

It is no secret that Americans worship the ideal of thinness, and as a consequence, disparage obesity. People often associate obesity with laziness, lack of success, and a weak will (Puhl & Heuer, 2010).  This bias is so culturally ingrained that it begins at a very young age. One study demonstrated that preschoolers tended to choose a thin or average sized playmate more often than they chose an overweight playmate (Frankova, 2000). A separate study showed that children age 3-5 assigned more negative characteristics to figures with larger body sizes (Spiel, 2012).

The research suggests that discrimination against obese people can be seen in:

Overweight job applicants are perceived as less suitable for employment than people who weigh less. As a consequence, they are hired less frequently and can find themselves at an economic disadvantage.

  • Romantic Relationships

In a study that looked at dating or married couples, heavier women had lower quality and less stable relationships (Boyes & Latner, 2009).  Partners rated heavier women as less warm, less trustworthy, and less attractive.  On the other hand, male partner’s weight did not have a significant impact on relationship functioning.

  • Education

-Kids can be cruel to their overweight peers. High school students identified being overweight as the primary reason that peers are victimized at school. Overweight teens experience frequent discrimination and even verbal threats and physical harassment (Puhl, 2011).  Teens who participated in a research study reported witnessing overweight peers being ignored, avoided, excluded from social activities, having negative rumors spread about them, and being teased in the cafeteria.

-It is not only kids who harbor this weight bias, but teachers too. One study found that 28% of teachers said that becoming obese is the worst thing that can happen to a person (Puhl & Brownell, 2001).

-Parents also discriminate against overweight children, and provide less college support for overweight children than for their thinner children (Puhl & Brownell, 2001).

  • Health Care:

-Obese individuals experience discrimination in healthcare settings and avoid medical care due to the fear of experiencing stigmatization (Puhl & Heuer, 2009).  This fear is not baseless. The weight of a patient significantly affects how physicians view and treat them. Studies show that although physicians prescribe more tests for heavier patients, they simultaneously spend less time with them, and view them more negatively (Hebl & Xu, 2001).

-In a study of nurses (Puhl & Brownell, 2001), 24% of the participants said that they are “repulsed” by obese persons.

-In a study of over 620 primary care physicians, more than 50% of physicians viewed obese patients as awkward, unattractive, ugly, and noncompliant. One-third of the physicians further characterized obese patients as weak-willed, sloppy, and lazy. Physicians also viewed obesity as largely a behavioral problem caused by physical inactivity and overeating, rather than as a complex issue with many potential causes  (Puhl & Heuer, 2009).

-A study of 255 British health-care professionals found that providers perceived overweight people to have reduced self-esteem, sexual attractiveness, and health. Providers believed that physical inactivity, overeating, food addiction, and personality characteristics were the most important causes of gaining excess weight (Puhl & Heuer, 2009).

 

Doctors’ ethical guideline of “first do no harm” is challenging when talking about issues of weight.  Clinicians may cause harm by saying something that contributes to further stigmatization of obesity. However, if a patient is carrying a truly dangerous amount of excess weight, it can be harmful not to say something. It is difficult to provide useful advice about weight management, as the research on effective long term weight treatments is quite limited. The key guide for clinicians in conversations about weight is to keep an open mind, to ask questions, and listen to patients without judgment.

 

Discrimination in employment, education, and health care settings is currently the focus of much research and activism, and we are likely to see many more campaigns promoting body size diversity, as well as new laws to protect the rights of fat people.

 

Discrimination Perpetuates Obesity

Clearly, the stigma and discrimination described above is profound. Experiencing such discrimination can cause harm to both mental and physical health. For overweight individuals in particular, being on the receiving end of discrimination may perpetuate the cycle of weight gain.

Adults who experience weight discrimination may use problematic coping strategies such as eating larger amounts of food (Puhl et al, 2007) and avoiding physical activity (Vartanian & Novak, 2011) in response to stress. This, in turn, perpetuates the cycle of weight gain. In a study of over 6,000 adults, aged 50 and older, participants answered questions about weight discrimination in 2006 and then at follow up in 2010 (Sutin & Terracciano, 2013).  Those reporting weight-related discrimination, were 2.5 times more likely to become obese and 3 times more likely to stay obese 4 years later than individuals who did not report weight discrimination Other types of discrimination, such as sex or race discrimination were unrelated to risk of obesity.

A recent review article by Brewis (2014) identifies 5 mechanisms by which fat stigma could reinforce obesity.

  1. Behavior Change: When people feel judged for being overweight they tend to avoid exercise and engage in disordered eating behaviors such as restricting or binge eating.
  2. Stress: Adults who experience weight discrimination may use problematic coping strategies such as eating larger amounts of food (Puhl et al, 2007) and avoiding physical activity (Vartanian & Novak, 2011) in response to stress. This perpetuates the cycle. Elevated stress related to discrimination elevates stress hormones, which contribute to a deposition of fat around the internal organs.
  3. Social Network Changes: Obese individuals tend to have less social support, and as a result may rely on unhealthy coping mechanisms.
  4. Social Inequality and Poverty: Obese individuals experience discrimination in employment, salary and access to opportunities.  The downward social and economic spiral contributes to stress and limits access to healthy food and recreation.
  5. Intergenerational: Biological effects of obesity during pregnancy increase risk for obesity in the child.

Women and children are particularly vulnerable to these five effects of stigma and discrimination.  Women experience greater weight-related discrimination inside the home, in public settings, and at their jobs.

As a society we will gradually evolve to include obesity in our diversity-consciousness and non-discrimination, and hopefully eliminate the negative biases toward weight in ourselves; yet as in the cases of race or sexual orientation this may take some time. Until then we need to make a conscious effort not to add to fat stigma in speech and action.