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5 Bias, Stigma, and Social Consequences of Obesity

       Rebecca L. Pearl1,2 and Christina M. Hopkins3

      ¹ Department of Clinical and Health Psychology, University of Florida, Gainesville, FL, USA

      ² Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA

      ³ Department of Psychology and Neuroscience, Duke University, Durham, NC, USA

      Ms. S is a 50‐year‐old Black woman with a body mass index (BMI) of 38 kg/m2. She is happily married with two children and is a successful professional. She has struggled with weight since she was a child, when she was called names like “elephant” by classmates and family members. The teasing stopped when Ms. S entered adulthood, but she can still feel her blood pressure rise in anticipation of seeing her father, who inevitably comments on what she is eating and tells her she would look pretty if she just lost a few pounds. She can also sense judgment from others in subtle ways: from clothing store clerks who seem to be assisting only the leaner customers; from the eye roll of the airline passenger seated next to her as she asks the flight attendant for a seatbelt extender; and from the supervisor who consistently talks to her about the importance of “wellness” while promoting less experienced coworkers over her. Ms. S is not sure if it is because of her weight, race, gender, age, or all four factors, but she feels invisible in society. Despite all of her accomplishments in life, she believes that she is a failure because she has been unable to control her weight. Ms. S typically avoids doctor’s visits after being scolded about her “choice” to put her health at risk by staying at a higher weight. However, she has become so distressed about her weight that she has decided to seek treatment from an obesity specialist.

      In this composite clinical vignette, societal attitudes about weight permeate the school environment, interpersonal relationships, employment, health care, and the day‐to‐day life of someone who moves through the world in a larger body. Unfortunately, the experience of bias and stigma due to weight is not uncommon in societies that idealize thinner bodies [1]. Weight bias refers to negative attitudes toward individuals who are perceived to have excess weight [2]. Weight bias is accompanied by the attribution of negative character traits to people with obesity (such as laziness or weakness) and blame for the perceived inability to control one’s weight [3]. Compared to people with a lower body weight, those with a higher weight are presumed to be weaker, unhealthier, and less intelligent, hardworking, motivated, attractive, and social [4]. Due to these negative stereotypes, blame, and overall prejudice due to weight, individuals with obesity can be mistreated, socially rejected, and generally devalued in society – known as stigmatization [4].

Figure 5.1 presents an ecological model of the different levels at which weight stigma may occur, adapted from a more general model of stigma processes by Cook et al. [5]. The broadest level of weight stigma is the societal or institutional level. This level includes laws or policies that promote stigmatization (or fail to prevent it), such as the lack of legal protection against weight discrimination in most of the United States and abroad [6]. This may also include policies within organizations – such as businesses or health care facilities – that allow for discrimination or maltreatment due to weight. In addition, the societal level can include media portrayals that may perpetuate negative stereotypes about obesity. For example, television shows and movies often portray characters with obesity as the targets of jokes or as the villain [7], and news stories about weight and eating are accompanied by images of people with obesity eating unhealthy food, being sedentary, or wearing ill‐fitted clothing with their heads cropped out in a dehumanizing manner [8]. Societal messages about obesity can trickle down into interpersonal interactions, such as discrimination in education or employment settings, social avoidance or rejection, teasing and bullying (particularly among youth), critical comments from family or friends, and overall unfair treatment due to weight. Importantly, many people internalize societal stereotypes and scorn, either through personal experiences of stigmatization or from absorbing the ever‐present negative messages about weight that surround them [9]. This weight bias internalization (or weight self‐stigma) is illustrated in the clinical vignette, in the patient’s self‐devaluing belief that she is a failure because she struggles with her weight.

A common misperception is that society’s acceptance of people with higher body weights has increased as the prevalence of obesity has risen. In fact, rates of perceived weight discrimination have increased along with rising obesity rates [10]. Rates of perceived weight‐based discrimination range from 20 to 45% among US women with obesity and 6 to 28% among US men with obesity [11]. Weight is also the leading reason for bullying among youth [12]. In addition, estimates suggest that over 40% of US adults report internalization of weight bias to some degree, and approximately 20% report high levels of this internalization [13].