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The Stigma of Obesity: A Review and Update

2009; Wiley; Volume: 17; Issue: 5 Linguagem: Inglês

10.1038/oby.2008.636

1930-739X

Rebecca M. Puhl, Chelsea A. Heuer,

Body Contouring and Surgery

Obese individuals are highly stigmatized and face multiple forms of prejudice and discrimination because of their weight ((1),(2)). The prevalence of weight discrimination in the United States has increased by 66% over the past decade ((3)), and is comparable to rates of racial discrimination, especially among women ((4)). Weight bias translates into inequities in employment settings, health-care facilities, and educational institutions, often due to widespread negative stereotypes that overweight and obese persons are lazy, unmotivated, lacking in self-discipline, less competent, noncompliant, and sloppy ((2),(5),(6),(7)). These stereotypes are prevalent and are rarely challenged in Western society, leaving overweight and obese persons vulnerable to social injustice, unfair treatment, and impaired quality of life as a result of substantial disadvantages and stigma. In 2001, Puhl and Brownell published the first comprehensive review of several decades of research documenting bias and stigma toward overweight and obese persons ((2)). This review summarized weight stigma in domains of employment, health care, and education, demonstrating the vulnerability of obese persons to many forms of unfair treatment. Despite evidence of weight bias in important areas of living, the authors noted many gaps in research regarding the nature and extent of weight stigma in various settings, the lack of science on emotional and physical health consequences of weight bias, and the paucity of interventions to reduce negative stigma. In recent years, attention to weight bias has increased, with a growing recognition of the pervasiveness of weight bias and stigma, and its potential harmful consequences for obese persons. The aim of this article is to provide an update of scientific evidence on weight bias toward overweight and obese adults through a systematic review of published literature since the 2001 article by Puhl and Brownell. This review expands upon previous findings of weight bias in major domains of living, documents new areas where weight bias has been studied, and highlights ongoing research questions that need to be addressed to advance this field of study. A systematic literature search of studies published between January 2000 and May 2008 was undertaken on computerized psychological, medical, social science, sport, and education databases including PsycINFO, PubMed, SCOPUS, ERIC, and SPORTDiscus. The following keyword combinations were used: weight, obese, obesity, overweight, BMI, fat, fatness, size, heavy, large, appearance, big, heavyweight, bias, biased, discrimination, discriminatory, discriminate, stigma, stigmatized, stigmatization, prejudice, prejudicial, stereotype(s), stereotypical, stereotyping, victimization, victimize(d), blame(d), blaming, shame(d), shaming, teasing, tease(d), unfair, bully, bullying, harassment, assumptions, attributions, education, health, health care, sales, employment, wages, promotion, adoption, jury, customer service, housing, media, television. Reference lists of retrieved articles and books were also reviewed, and manual searches were conducted in the databases and journals for authors who had published in this field. Most studies retrieved for this review were published in the United States. Any articles published internationally are noted with their country of origin. Research on weight stigma in adolescents and children was excluded from this review, as this literature was recently reviewed elsewhere ((8)). Unpublished manuscripts and dissertations were also excluded. In addition, issues pertaining to measurement of weight stigmatization, and demographic variables affecting vulnerability to weight bias such as gender, age, race, and body weight are not addressed in this review. This article instead primarily reviews the evidence of specific areas where weight bias occurs toward adults and its consequences for those affected. This article is organized similarly to the first review published by Puhl and Brownell ((2)), with sections on weight bias in settings of employment, health care, and education. New sections have been added including weight bias in interpersonal relationships and the media, as well as psychological and physical health consequences of weight bias, and the status of stigma-reduction research. As with the 2001 article, this review also provides an update on legal initiatives to combat weight discrimination, and outlines specific questions for future research. In their 2001 review, Puhl and Brownell summarized research documenting weight-based prejudice and discrimination in employment settings ((2)). At that time, emerging evidence demonstrated that overweight and obese workers face stereotypical attitudes from employers and disadvantages in hiring, wages, promotions, and job termination because of their weight. Since then, there has been an increase in survey research, large population-based studies, and experimental work addressing weight discrimination in employment. Findings are summarized below. Self-report studies indicate that perceptions of weight-based employment discrimination remain common among obese persons. In one survey study of overweight and obese women (N = 2,249), 25% of participants reported experiencing job discrimination because of their weight. In addition, 54% reported weight stigma from co-workers or colleagues and 43% reported experiencing weight stigma from their employers or supervisors ((9)). Examples of weight stigma in employment settings included being the target of derogatory humor and pejorative comments from co-workers and supervisors, and differential treatment because of weight such as not being hired, being denied promotions, or fired because of one's weight. Several recent studies have examined weight discrimination in employment settings using data from the National Survey of Midlife Development in the United States, a nationally representative sample of adults ages 25–74 years. One study (N = 2,838) found that overweight respondents were 12 times more likely, obese respondents were 37 times more likely, and severely obese respondents were 100 times more likely than normal-weight respondents to report employment discrimination. In addition, women were 16 times more likely to report weight-related employment discrimination than men ((10)). Another study using the data of National Survey of Midlife Development in the United States (N = 2,290) found that among individuals who reported weight discrimination in employment almost 60% had experienced this mistreatment an average of four times during their lifetime. The specific types of employment discrimination reported included not being hired for a job, not receiving a promotion, and wrongful termination ((4)). Instances of wrongful termination that have been filed in legal cases typically involve an obese employee who was fired because of his/her weight despite positive performance evaluations and/or despite weight being unrelated to job duties. To date, most studies reflect perceptions by employees that weight was the deciding factor for job termination. A third study analyzing data of National Survey of Midlife Development in the United States (N = 3,437) found that 26% of obese persons and 31% of very obese persons reported discrimination in the workplace, which they attributed to their weight and appearance. Furthermore, very obese persons working in professional jobs were more likely than obese nonprofessionals to report employment discrimination ((11)). Several studies analyzing data from the National Longitudinal Survey of Youth suggest that obesity also negatively affects wages. In one study (N = 12,686), a consistent wage penalty for obese employees was demonstrated, even after controlling for socioeconomic and familial variables, and health limitations. For obese men, the wage penalty ranged from 0.7 to 3.4%. For obese women, the wage penalty was greater and ranged from 2.3 to 6.1% ((12)). The authors suggested that discrimination in training opportunities may explain some of the obesity wage penalty, although it should be noted that they did not test for employer-based discrimination. Another study using National Longitudinal Survey of Youth data (N = 25,843) found that for white females, an increase of 64 pounds above average weight was associated with a 9% decrease in wages, which was approximately equivalent to the difference of 1.5 years of education or 3 years of work experience ((13)). A third study analyzed data from the 1988 wave of the National Longitudinal Survey of Youth when respondents were 23–30 years old (N = 6,601). This analysis revealed that both black and white obese women experienced significant wage penalties, even after controlling for socioeconomic status and other related variables. Compared to their normal-weight counterparts, mildly obese and severely obese white women experienced a decrease in wages of 5.8% and 24%, respectively. Similarly, mildly obese and severely obese black women's wages were 3.3% and 14.6% less than normal-weight black women's wages, respectively. Severely obese white men earned 19.6% less and severely obese black men earned 3.5% less than their normal-weight counterparts ((14)). Other cross-sectional research supports these findings. In a study examining adults living in countries belonging to the European Union (N = 17,767 women and 34,679 men), it was observed that a 10% increase in the average BMI reduced the hourly wages of males by 1.9% and females by 3.3%. In Southern European countries, where citizens are reportedly more concerned with weight gain, the effect was much larger ((15)). Other work analyzing data from the 1984 National Lawyer Survey (N = 722) found that overweight male lawyers were paid less than normal-weight male lawyers ((16)). Weight bias may also help explain studies documenting lower rates of employment for obese individuals. For example, Klarenbach and colleagues analyzed data from the Canadian Community Health Survey, a population-based household survey of over 73,500 individuals. The study found obesity to be associated with lower workforce participation, independent of associated comorbidities and sociodemographic factors ((17)). In addition, a study using data from a nationwide prospective cohort in the United States (N = 4,290) estimated the effect of obesity on future employment. After adjusting for sociodemographic characteristics, smoking status, exercise, and self-reported health, obesity was associated with reduced employment for both men and women ((18)). Other population-based studies from outside the United States support these findings ((19),(20),(21),(22)). Experimental research provides key evidence of causal links between weight-based discrimination and hiring decisions. Typically, experimental studies ask participants to evaluate a fictional applicant's qualifications for a job, where his or her weight has been manipulated (through written vignettes, videos, photographs or computer morphing). Roehling and colleagues recently conducted a meta-analysis of 32 experimental studies investigating weight discrimination in employment settings ((23)). Studies were included in the analysis if they involved simulated employment decisions and demonstrated an effect size between target weight and job-related outcome variables. Outcome variables included hiring recommendations, qualification/suitability ratings, disciplinary decisions, salary assignments, placement decisions, and coworker ratings. Across studies, it was demonstrated that overweight job applicants and employees were evaluated more negatively and had more negative employment outcomes compared to nonoverweight applicants and employees. The authors additionally assessed a number of moderators that may influence the relationship between weight and discriminatory attitudes. Potential moderators included both target and rater characteristics such as gender and race, and the type of job for which targets were evaluated. Although rater characteristics did not significantly influence the relationship between weight and employment ratings, several traits of the target emerged as important moderators. First, findings showed that both overweight men and women were equally susceptible to weight discrimination in the workplace, which challenges some previous research documenting gender differences in weight bias ((4),(24)). The authors suggest that their finding should be interpreted with caution, as some research suggests that weight-based employment discrimination may occur at lower weight levels for women than for men ((4),(14),(22)), and the majority of the studies included in the meta-analysis contrasted a nonoverweight target with an obese target. If studies manipulated a wider range of weight levels and different forms of weight discrimination, greater differences may have been observed between men and women. The meta-analysis also showed that overweight employees were more disadvantaged than nonoverweight applicants when they were being evaluated for jobs that required extensive public contact, and when they were rated for their desirability as a coworker. In addition, white targets were more heavily penalized in employment decisions than overweight African Americans. However, these findings should also be interpreted cautiously because only two studies investigated the effect of race. Given that African Americans can be targets of racial bias, it may be difficult to disentangle the effects of weight bias among other layers of prejudice. Finally, several methodological variables influenced results across studies. When participants were provided with a relatively large amount of job-relevant information prior to making their evaluations, the relationship between the target's weight and employment outcomes were weaker compared to studies where little job-relevant information was provided. The effects of weight discrimination were also stronger in studies that pilot-tested the weight manipulation information and in studies that presented the target's weight through written or verbal descriptions vs. videos or photographs ((23)). These experimental findings clearly demonstrate that overweight and obese individuals are disadvantaged in workplace interactions, evaluations, and employment outcomes as a result of negative weight-based stereotypes. Research to date suggests that the most common stereotypes about obese employees include views that they are less conscientious, less agreeable, less emotionally stable, and less extraverted that their normal-weight counterparts ((25),(26),(27),(28)). To investigate the validity of common stereotypes about overweight job applicants and employees, Roehling and colleagues conducted two studies to examine the relationship between body weight and four relevant personality traits (conscientiousness, agreeableness, emotional stability, and extraversion) ((29)). In the first study using a nationally representative sample of 3,176 adults, BMI was compared with personality trait measures from the Midlife Development Inventory Personality Scales. Findings showed that the relationship between personality and demographic variables (age or gender) was stronger than the relationship between BMI and personality traits. The second study compared body weight and personality traits from the NEO Personality Inventory (Short Form) in 320 college students. No evidence was found for differences in personality characteristics based on weight. These findings help challenge commonly held stereotypes about negative personality traits of overweight employees. Recent survey and population-based studies show that high percentages of obese workers perceive consistent weight-based disparities in employment settings. Their perceptions are supported by large-scale studies documenting lower wages for obese employees, and experimental research demonstrating that overweight job applicants experience discrimination in hiring and employment decisions. Future work should examine a wider range of weight levels, job types, gender and race interactions with weight, and both subtle and overt forms of bias to help provide a clearer understanding of weight discrimination in the workplace. It will also be useful to assess potential mediators and contextual factors (e.g., employer concerns about rising health-care costs) that may influence employment outcomes for obese individuals. Overweight and obese patients are vulnerable to multiple forms of weight bias in health-care settings. In 2001, Puhl and Brownell summarized a number of studies demonstrating that health-care professionals (e.g., physicians, nurses, psychologists, and medical students) possess negative attitudes toward obese patients, including beliefs that obese patients are lazy, noncompliant, undisciplined, and have low willpower ((2)). Research since 2001 expands upon this body of knowledge, providing new insight into providers' attitudes and weight management practices, and health-care experiences of obese patients. In recent years, increasing research in the United States and abroad demonstrate that health-care providers in a range of specialty areas endorse stereotypical assumptions about obese patients and attribute obesity to blameworthy causes. Physicians. In a study of over 620 primary care physicians, >50% viewed obese patients as awkward, unattractive, ugly, and noncompliant. One-third of the sample 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 ((30)). A study of British health-care professionals (N = 255) 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 overweight ((31)). In a study of 600 general practitioners (GPs) in France, 30% considered overweight and obese patients to be lazier and more self-indulgent than normal-weight people, and 60% identified lack of patient motivation as the most common problem in treating overweight and obese patients. GPs also considered "eating too much' as the most important risk factor for obesity, ranked above genetic and environmental factors. Providers who endorsed negative attitudes toward obese patients were less likely to subscribe to medical journals, suggesting that GPs may not have been familiar with current research examining the complex causes of obesity ((32)). Another French study found that 73% of GPs (N = 607) agreed that health professionals hold negative attitudes toward their obese patients. GPs ranked patient noncompliance and lack of motivation as the most important problems they experienced in treating obesity ((33)). A study of 752 Australian GPs found similar results, where providers reported that their most common frustrations in weight management were patients' lack of compliance and motivation ((34)). Likewise, an Israeli study showed that 31% of family physicians (N = 510) agreed that overweight people tend to be lazier than normal-weight people and 25% agreed that overweight people lack willpower and motivation compared to normal-weight people ((35)). In a British qualitative study, primary care physicians (N = 21) reported beliefs that obesity was caused by an unhealthy diet and lack of exercise and that it was the responsibility of the patients themselves to manage their weight. Physicians expressed frustration that patients made excuses as to why they could not comply with lifestyle recommendations. Despite these frustrations, physicians expressed an interest in maintaining positive provider-patient relationships ((36)). In contrast, a study examining attitudes of military family physicians (N = 214) found that providers reported generally positive attitudes toward obese patients. However, 25% indicated that their obese patients were lacking in self-control ((37)). Experimental work supports findings of self-report studies. Hebl and Xu examined how a patient's body weight influences attitudes among primary care physicians (N = 122), who viewed one of six vignettes depicting patients who were identical except for sex (male/female) and BMI (23, 30, or 36 kg/m2). The results revealed a strong, consistent linear trend in the way that physicians responded to the size of patients. As the patient became heavier, physicians judged them to be less healthy, worse at taking care of themselves, and less self-disciplined. In addition, as patient BMI increased, physicians reported liking their jobs less, having less patience, and less desire to help the patient. Physicians also reported that seeing obese patients was a greater waste of their time and that heavier patients were more annoying than patients with lower body weights. Furthermore, physicians predicted that heavier patients would be less likely to comply with medical advice and would be less likely to benefit from counseling ((38)). Since 2000, two studies have employed the Implicit Association Test to assess implicit antifat bias among health professionals who specialize in treating obesity. Both studies found there to be a strong implicit antifat bias among clinicians and researchers specializing in obesity. Teachman and Brownell found that health professionals (N = 84) associated "fat people" with negative attributes such as "bad" and "lazy" and "thin people" with positive attributes, such as "good" and "motivated". Participants also endorsed the explicit belief that thin people are more motivated than fat people ((39)). Schwartz and colleagues found that health professionals (N = 389) endorsed both the implicit and explicit stereotypes that fat people are lazy, stupid, and worthless ((40)). Despite common beliefs that obese patients lack motivation to make lifestyle changes and are noncompliant with treatment recommendations ((32),(34),(35),(41)) there is evidence to suggest that physicians' perceptions of patient motivation may be misguided. Befort and colleagues found that, patients' self-reported level of motivation regarding weight management was significantly higher than physicians' perceptions. A motivation level of "10 = completely motivated" was reported by 30% of female and 21% of male patients, whereas physicians rated only 2.5% and 3.1% of their female and male patients, respectively, as being a "10". Similarly, some research suggests that physicians and patients have different perceptions about the causes of obesity, which may influence endorsement of weight stigma. In one United Kingdom study, GPs (n = 89) reported a victim-blaming approach toward obesity, deeming the individual responsible for both the cause (e.g., eating too much) and the solution to their weight problem. However, patients (n = 599) in the study were more likely to attribute obesity to medical causes or low income ((42)). Differences in perceived motivation or causes of obesity between doctor and patient may hinder positive communication regarding weight management or healthy lifestyle changes ((43)). Nurses. Recent research has also demonstrated negative attitudes toward obese patients among nurses. A 2006 review of research focusing on nurses' attitudes toward adult overweight and obese patients reported that nurses consistently express biased attitudes toward obese patients, reflecting common weight-based stereotypes that obese patients are lazy, lacking in self-control, and noncompliant ((41)). In a British study of 398 nurses, nearly 69% agreed that personal choices about food and physical activity explain why a person becomes obese, one-third agreed that obesity is due to a lack of willpower concerning food, and only 8.2% agreed that obese people are motivated about lifestyle change ((44)). Nurses with lower BMIs expressed more negative perceptions of obesity. Brown and Thompson conducted qualitative interviews of 15 primary care nurses in England concerning their attitudes and beliefs toward obesity management. Although nurses were aware that obesity is a stigmatized condition and were careful to avoid weight-based stereotypes, some expressed frustration with patients' noncompliance and wanting an "easy way out". Nurses with high BMIs felt self-conscious about their size and reported that patients made rude comments about their weight ((45)). Contrary to other studies assessing nurses' attitudes toward obese patients, a 2006 study found that registered nurses (N = 119) had positive attitudes toward adult obese patients and that nurses were concerned with providing respectful patient care. However, these findings should be interpreted with caution due to the study's low response rate (16.2%), which may indicate that only nurses who are sensitive to the needs of the obese patients chose to complete and return the survey ((46)). Medical students. Medical students express many of the same negative attitudes toward obese patients as more seasoned health professionals. Wear and colleagues examined attitudes of medical students (N = 54) toward a variety of patients, and found that the students reported, with nearly total agreement, that severely obese patients were the most common target of derogatory humor by attending physicians, residents, and students, which occurred most often in surgery and obstetrics-gynecology settings ((47)). Students indicated that their denigration of obese patients was due to both the assumption that patients were to blame for their condition and because patients' obesity caused extra work for students. Students reported that overweight and obese children were also targets of humor. Most of the students did not consider derogatory humor directed toward obese patients to be inappropriate. In another study, medical students (N = 48) were randomly assigned to view videotapes of actors pretending to be either average weight patients or obese patients (by using padding and bulky clothing) visiting their physician for the first time. Students who viewed tapes of the obese-appearing patients predicted that the patients would be less likely to make lifestyle changes, would not be as responsive to counseling, and would be less likely to comply with treatment recommendations, compared to students who viewed average weight patients. Patients who appeared obese were also rated by students as less attractive, less compliant, and more depressed than average weight patients ((48)). Similarly, dental students have reported negative attitudes toward obese patients. One study (N = 420) found that nearly one-third of dental students acknowledged having negative reactions toward the appearance of obese patients, 30% felt that obese people are lazier than nonobese people, 26% felt that obese people lacked willpower and motivation, 18% were uncomfortable examining an obese patients, and 17% considered it difficult to feel empathy for an obese patient ((49)). Fitness professionals and dietitians. Fitness professionals and exercise science students also express weight bias. In a study of fitness professionals (N = 325), 62% agreed that obesity is a significant cause of personal rejection, and most participants believed that personal factors such as sedentary lifestyle, poor eating behaviors, and psychological problems were the most important causes of obesity ((50)). Using the Implicit Association Test, other research has documented a strong implicit antifat bias among exercise science students (N = 246). Being female, white, and having a lower BMI were all associated with stronger implicit antifat bias. Students also endorsed explicit attitudes that fat people are lazy, physically unattractive, buy too much junk food, and could lose weight if they really wanted to do so ((51)). Recent work suggests that dietitians are not immune to weight bias. Berryman and colleagues assessed negative attitudes toward obesity among dietetics and nondietetics students ((52)). Both groups (N = 76) exhibited moderate levels of fat phobia as a whole and 16% of both groups exhibited high levels of fat phobia. The majority of students (ranging from 71 to 91%) agreed or strongly agreed with the stereotypes that overweight people overeat, are inactive, slow, insecure, shapeless, and have no endurance, low self-esteem, and poor self-control. Over half of students agreed or strongly agreed that overweight people are unattractive, have no willpower, and are lazy. The authors conclude that dietetics curriculum does not adequately dispel weight bias. A study of 187 British dietitians found that although attitudes were mixed, dietitians rated obese people less positively than overweight people and indicated that obese people were more responsible for their excess weight than overweight people ((53)). Another study found that Australian dietitians (N = 400) reported frustration with their overweight and obese clients' lack of commitment and motivation, poor compliance, and unrealistic expectations ((54)). Most recently, Puhl and colleagues used an experimental design to assess weight bias among dietetics students ((55)). One hundred and eighty-two dietetic students were randomly assigned to read one of four patient health profiles that varied only by weight and gender. Compared to students who read nonobese patient profiles, students who read obese profiles rated the patients as less likely to comply with treatment recommendations and as having worse diet quality and health status, despite the fact that dietary and lifestyle information were identical across conditions. In contrast, obese and nonobese patients were rated to be similarly motivated. In addition, participants in all conditions expressed a moderate amount of fat phobia, similar to findings of Berryman et al. The majority of the dietetic students (ranging from 54 to 81%) agreed that obese individuals h