Social stigma of obesity

Research indicates that self-reported incidents of weight-based discrimination increased from 1995 to 2006.[9] Individuals who are subjected to weight-related stigma appear to be rated more negatively when compared with other groups, such as sexual minorities and those with mental illness.[10]

Anti-fat bias has been observed in groups hoping to become physical education instructors. In a study published in 2007, a group of 344 psychology or physical education majors at a New Zealand University were compared, and it was found that the prospective physical education teachers were more likely to display implicit anti-fat attitudes than the psychology majors.[11]

A number of studies have found that health care providers frequently have explicit and/or implicit biases against overweight people, and it has been found that overweight patients may receive lower quality care as a result of their weight.[12] Medical professionals who specialize in the treatment of obesity have been found to have strong negative associations toward obese individuals.[13] The stress from obesity-related stigma may also cause negative health outcomes.[4]

In one study, preschool-aged children reported a preference for average-sized children over overweight children as friends.[14] Overweight individuals often find themselves suffering repercussions in many facets of society, including legal and employment issues later in their life.[6]

According to a 2010 review of published studies, interventions seeking to reduce prejudice and social stigma against fat and obesity are largely ineffective.[15]

Weight-related stigma can be characterized by the following aspects:

1. An individual does not have to be overweight or obese to experience weight-related stigma.[16]
2. Studies have indicated that experiencing weight stigma reinforces lifestyle behaviors that contribute to obesity.[17]
3. Many groups who are subjected to stigmatisation tend to be minorities. Overweight and obese individuals make up the majority of the population in the United States and in other parts of the world.[18]
4. Individuals who are overweight or obese tend to devalue their own in-group and prefer the out-group (i.e. thinner individuals).[19]

In order to understand weight-biased attitudes, theories have been proposed to explain these biases and the subsequent discrimination they cause. Christian S. Crandall discusses the "Justification of Stigmatization".[20] Also his Social Ideology Perspective draws on traditional North American values of self-determination, individualism, and self-discipline. Based on these values, anti-fat attitudes may derive from directing blame for being overweight towards individuals who are overweight.[21] Similarly, the attribution theory suggests that attitudes towards obese individuals are dependent on how much control they are perceived to have over their weight.[2] Throughout the literature, numerous studies have shown support for this theory. One study conducted a multinational examination of weight bias across four countries (Canada, United States, Iceland, and Australia) with comparable obesity rates.[22] The study found that attributions of behavioral causes of obesity were associated with greater weight bias. Similarly, viewing obesity as being caused by a lack of willpower was also associated with greater weight bias. There appears to be a decrease in weight bias when weight is attributed to factors that are less within the individual's control, or when individuals are perceived as trying to lose weight.[23] However, evidence also exists showing that biases against obese individuals also include disgust towards them, which can persist regardless of if one knows that obesity is not caused by obese individuals' actions.[24]

Fatphobia is a socially constructed phenomenon of particular prevalence in the western world. Societies produce the sort of bodies they need.[25] The west values healthy and strong bodies that prioritize agility, endurance and fertility[26] - with focus on achievement and individual responsibility.[27] Not only do such bodies associate the western world with similar ideals, but Lloyd deMause suggests the ‘fitness/toughness craze’ may also reflect preparations for war.[28] The ’fattening huts’ of young girls in Nigeria however, represent beauty, marriageability and money – a direct reflection of the value of economic resource and food.[29] Fatness is a welcome sign of health, prosperity and maternity - linked to self-worth and sexuality also.[30]

Fatphobia does not fear ‘fat’ but prejudice, discrimination, exclusion and preventable disease too - fears directly attributable to the myriad of social, political, historical, economic and cultural processes at work (that do not similarly exist in other cultures).[31] In this way, fatphobia is a culturally-derived phenomenon influencing relationships to food as well to the female form. Trends in ‘blame, shame and stigma'[32] have contributed to fat positivity and ‘health at every size’ movements, that create digital ‘safe spaces’ for activism and radical fat acceptance that seek to resist/shift such powerful cultural perspectives.[33]

Anti-fat bias leads people to associate individuals who are overweight or obese with negative personality traits such as "lacking willpower",[34] "lazy", "gluttonous", "stupid", "incompetent", or "unmotivated".[35] This bias is not restricted to clinically obese individuals. It also encompasses those whose body shape is found to be unacceptable when compared to modern society's perception of the ideal body type (although still within the normal or overweight body mass index (BMI) range).[36] Fat-shaming is fairly common in the United States, even though most adult Americans are overweight. Huffington Post wrote "two-thirds of American adults are overweight or obese. Yet overweight and obese individuals are subject to discrimination from employers, healthcare professionals, and potential romantic partners".[37]

Anti-fat bias can be moderated by giving a mitigating context to the individual's appearance of obesity.[38] For example, when told an individual was obese because of "overeating" and "lack of exercise", a higher implicit bias was found among study participants than those not provided with context. When the group was told that "genetics" was to blame, they did not exhibit a lowered implicit bias after the explanation.

Anti-fat bias is not a strictly Western cultural phenomenon. Instances of implicit anti-fat bias have been found across several cultures.[39]

Additionally, recent work around physical appearance issues, body image, and anti-fat or obesity prejudice suggests that feelings about one's own appearance may stimulate downward physical comparisons with obese individuals in order to make one feel better about one's own physical appearance.[40][41]

Weight stigma is present in multiple settings including healthcare, education, interpersonal situations, multiple media forms and outlets, and across many levels of employment.[2]

In politics

New Jersey Governor Chris Christie is a politician who was subjected to weight-related discrimination during his political career.[46]

A study by Michigan State University researchers shows evidence that overweight political candidates tend to receive fewer votes than their thinner opponents.[58] The researchers analyzed data from the 2008 and 2012 U.S. Senate elections. Using a previously established scientific method, research assistants determined from color photos whether the candidates in 126 primary and general elections were of normal weight, overweight, or obese.

Both obese men and women were often less likely to get on the ballot in the first place. When it came to merely being overweight, women were seen underrepresented on the ballot, though men were not. This is consistent with previous research showing slightly overweight men tend not to experience the same discrimination as slightly overweight women.

However, when it came to the voting, both male and female candidates, whether obese or simply overweight, tend to get a lower share of the vote total than their more slender opponents. Some politicians have resorted to extreme weight loss measures, including surgery, to increase their elect-ability to political office. [59]

In adulthood, individuals who experience weight discrimination are more likely to identify themselves as overweight regardless of their actual weight status.[77] The experience of weight stigma can function as motivation to avoid stigmatizing environments, and although it may motivate one to escape stigma through weight loss, it undermines one's capacity to do so.[78] Researchers have linked weight stigma to decreases in physical activity,[77][79][80] decreases in seeking health care[80] and increases in maladaptive eating patterns such as binge eating.[78][80] In addition, those who have experienced weight stigma have shown altered cardiovascular reactivity, increased cortisol level, oxidative stress, and inflammation.[78]

People who expect to be fat-shamed by healthcare providers are less likely to seek care for medical issues or for weight loss, even if the weight gain is caused by medical problems.[81]

In terms of psychological health, researchers found that obese individuals demonstrated a lower sense of well-being relative to non-obese individuals if they had perceived weight stigmatization even after controlling for other demographic factors such as age and sex.[82] Overweight and obese individuals report experiencing forms of internalized stigma such as body dissatisfaction as well as decreased social support and feelings of loneliness.[83][84] In addition, similar to findings in adolescence, weight stigma in adulthood is associated with lower self-esteem, higher rates of depression, anxiety, and substance abuse.[78][80][83]

In both adults and children with obesity, several reviews of the literature have found that across a variety of studies, there is a consistent relationship between experiencing weight stigma and many negative mental and physical health outcomes.[2][21][85][56][86] These will be discussed separately in the sections below, although physical and mental health consequences are often intertwined, in particular those related to eating disorders.

Papadopoulos and Brennan (2015) recently found that across many reviewed studies of weight loss treatment-seeking adults,[85] relationships emerged between experiencing weight stigma and both BMI and difficulty losing weight. However the findings are somewhat mixed. They also report evidence that experiencing weight stigma is related to poor medication adherence. Among weight loss treatment-seeking adults, experiencing weight stigma might exacerbate weight- and health-related quality of life issues.[85] This review along with reviews by Vartanian and Smyth (2013) and Puhl and Suh (2015) have also found that across several studies and in both adults and children, experiencing weight stigma is related to decreased exercise behavior overall, as well as decreased motivation to exercise, decreased exercise self-efficacy, and increased food craving and tendency to overeat.[21][85][65] It is important to note that these effects of weight stigma on exercise and physical activity emerge independent of body mass index, suggesting that weight stigma becomes a unique barrier to physical activity outside of barriers that may be associated with obesity in particular. Finally, across many studies, Puhl and Suh (2015) also found that experiencing weight stigma is related to many physiological consequences as well, including increased blood pressure, augmented cortisol reactivity, elevated oxidative stress, impaired glycemic control/elevated HbA_1c, and increased systemic inflammation,[65][86] all of which have notable consequences for physical health and disease.

Over the past few decades, many scholars have identified weight stigma as a long-standing form of social stigma and one of the last remaining socially acceptable forms of prejudice.[88] It follows then that individuals who are targets because of overweight and obesity, still face uniquely socially acceptable discrimination.[89][90] Civil rights legislation such as Title VII of the Civil Rights Act of 1964 prohibits discrimination based on race and several other domains, but weight is not included in this act. At the local level, only one state in the US (Michigan) has policy in place for prohibiting weight-related employment discrimination and very few local municipalities have human rights ordinances in place to protect individuals of large body size.[2][91] Typically, the only type legislation that overweight and obese individuals can cite in lawsuits is related to disability. For example, the Americans with Disabilities Act is one such avenue, but as Puhl et al. (2009) report, it is difficult for many individuals with obesity to qualify as disabled according to the criteria included in this statute.[2]

The existing literature largely does not support the notion that weight stigma might encourage weight loss; as cited above, experiencing weight stigma (both interpersonally as well as exposure to stigmatizing media campaigns) is consistently related to a lack of motivation to exercise and a propensity to overeat.[21][85][65] In a 2010 review examining whether weight stigma is an appropriate public health tool for treating and preventing overweight and obesity, Puhl and Heuer concluded that stigmatizing individuals with obesity is detrimental in three important ways: (1) it threatens actual physical health, (2) it perpetuates health disparities, and (3) it actually undermines obesity treatment and intervention initiatives.[17] In line with this, another recent review of the consequences of experiencing weight stigma, this one conducted by Puhl and Suh (2015), concluded that considering the myriad negative physical and mental health consequences associated with experiencing weight stigma, it should be a target, instead of a tool, in obesity prevention and treatment.[65] These authors further recommend that a necessary first step in reducing weight stigma is raising broader awareness of its negative consequences.[65]

With higher representation of black people being categorized as overweight by the BMI, the social stigma of obesity disproportionately affects black people.[92] More than 80% of African American women are categorized as overweight using the Body Mass Index.[93] Yet, the BMI was created based on a group of European men and cutoffs have been altered in the US in a non-scientifically verified way, with no distinguishing between appropriate cutoffs for different races.[94]

Sociologist Sabrina Strings writes, in her book Fearing the Black Body, about the historical ways in which fatphobia emerged out of an attempt by white people to distance themselves from black people. In 1751, Denis Diderot published the Encyclopédie, which was the first publications to claim that black people were "fond of gluttony."[95] In 1853, French aristocrat Arthur de Gobineau claimed, about black people, that their "gluttonous nature to be one of their more base characteristics."[96] In 1910, Charles Davenport founded the Eugenic Record Office, and he claimed that "obesity was a vile condition to be avoided. It was, moreover, racially inherited."[96] Eugenics sentiment toward black people regarding their size was prevalent.

Body standards differ between black and white communities, but whiteness, and therefore thinness, is seen as the cultural norm. Scholar Elizabeth Hughes discusses this in "I'm Supposed to be Thick:" Managing Body Anxieties Among Black American Women," citing the norm of a "thick" body type, in other words curvier bodies, in the black community.[97]

Black bodies are already stigmatized, which can result in violence when interacting with the social stigma of obesity. In a 2017 article published in the African American Review, one author cited the killing of Eric Garner as an example of this, as some excuses for using excessive force on Garner were his size, as he was an overweight man.[98] The article explains how ableism, fatphobia, and racism interact to form a "double bind" in which violence is excused because fatness is already causing inherent injury, but necessary because the size of a large black person is a threat.

A paper published by the American Journal of Preventive Medicine titled “Intersectionality: An Understudied Framework for Addressing Weight Stigma”[99] focused on highlighting the intersectionality between weight stigma and health-related coping responses across several non-white racial and gendered groups. The findings of this publication demonstrated that there were no significant differences in weight stigma as a function of race or gender, having an overall equal representation across all racial groups analyzed. Nonetheless, results additionally demonstrated that different racial groups had differing ways of internalizing and coping with weight and health-related stigmas, which as a result heightened health risks. Results revealed that white women and men reported higher weight bias internalization in comparison to black women and men. Additionally, Hispanic women demonstrated to cope with weight stigma via disordered eating patterns more than black and white women. The results of this research article highlighted the importance of needing to increase research and policy attention to addressing weight and health-related stigma as an issue regarding prevention and treatment for obesity in order to consequently decrease weight-driven inequalities in communities and differing groups, primarily focused on race and gender.

Preference regarding language varies widely amongst overweight individuals, though there is some consensus on generally unaccepted terms.

Person first language is not ubiquitous among fat acceptance movements, and in fact people view it as an “inherent adverse judgment.” Those who promote person-first language, i.e. using terminology such as a person with obesity, seem to have done so without consultation in fat activist groups.[100] Critics of person-first language cite problems with the desire to separate a person from that characteristic, as separating it implies that there is something wrong with being overweight, which contributes to further stigma.[100] Furthermore, person-first language contributes to the medicalization of obesity, as the language is commonly used when referring to disease.[100]

The term "fat" appears to result in more stigma and judgement from the broader community. Various studies of overweight people seeking weight loss as well as a semantics study of varied terminology used to describe an overweight individual conclude that using the word fat elicits a negative reaction from people already critical of obesity.[101][102] Regarding other terms, "obesity" was found in one study to be equally as undesirable as "fat" when considering language preferences of overweight individuals.[100]

Yet, "fat" is the preferred term within the fat acceptance movement.[103] Fat activists have reclaimed the term as a neutral descriptor in order to work against the stigma typically associated with the term.[100] In fact, many fat activists will censor the word "obesity" when tweeting or citing it as "ob*sity" due to its pathologizing nature. The word "obesity" directly stems from the latin word "obesus" which means "that has eaten itself fat".[104] Fat activists will also use this latin definition to show stigma in the word "obese" itself, as it places blame on the individual for their state.[105]

Fat activist Aubrey Gordon argues that "disavowing the term fat reinforces its negative meanings."[105] Although studies have not been conducted among fat activists on preferred terminology, books such as What We Don't Talk About When We Talk About Fat, Happy Fat, Things No One Tells Fat Girls, and Fat! So? all have the word Fat in the title in a non-derogatory sense. Likewise, The National Association to Advance Fat Acceptance (NAAFA) was founded in 1969, with the descriptor of the community being "fat."[105]

• Fat acceptance movement
• Fattitude—2017 documentary on fat discrimination
• Height discrimination
• Reddit anti-fat communities
• Sizeism

• Hobbes, Michael (19 September 2018). "Everything You Know About Obesity Is Wrong". Highline. The Huffington Post.