Think back to your time in school and try to remember how the overweight children were treated. It is possible that you were the subject of such treatment, but if not, imagine how this would feel and whether such experiences could have an indelible impact. What are the consequences of such treatment then and later in life? When people think of stigma, bias, discrimination factors such as gender, race, and age come to mind for most people, but not necessarily weight. And weight bias is a very important topic and has been the subject of an impressive body of research.
About Rebecca Puhl
A leader in this area is Dr Rebecca Puhl, professor of Human Development Family Studies at the University of Connecticut and the deputy director of the Rudd Center for food policy and obesity. Dr Pull is a leading voice in both research and in policy efforts aimed at reducing weight based discrimination, stigma, and victimization. She's conducted research on weight stigma for more than 16 years and has numerous publications on the issue. She has testified in legislative hearings on weight discrimination and routinely provides expertise on strategies to reduce weight bias to national and international health organizations. She's received numerous awards for her work from national organizations.
Rebecca, I give you credit for what I believe you people can claim you really created a field before you began your work on weight stigma, one could count the studies on the topic on one hand. But you made this an area of legitimate scientific inquiry and because of the work you and your colleagues have done, a robust field now exists and much has happened.
The subject of weight bias may seem like an academic matter, but there's a real human cost. Can you paint a picture of how people are affected by this and what sort of things actually happen in people's lives? And why don't we begin with a discussion of children?
Well, most of the attention to childhood obesity typically focuses on children's physical health? But we know from considerable research that the social consequences of being teased or bullied because of weight can be really devastating for kids. And weight stigma begins early in life for children. Some studies have found that even by preschool, three and five year olds are already endorsing negative stereotypes about their peers who have a larger body size. And by elementary school, many children are being teased and bullied about their weight. And unfortunately this really continues throughout adolescence. And what we know is that these experiences can take multiple forms. So weight stigma for kids means being socially excluded from their peers. Being verbally teased or insulted because of their weight. Being the target of cyber bullying or physical aggression. And you know, these experiences can really result in damaging emotional and physical health consequences for children and adolescents.
We know that they have an increased risk of things like depression and anxiety, poor self-esteem, poor body image. But it can also lead children and adolescents to turn to unhealthy eating behaviors too. Like binge eating or unhealthy weight control practices, avoiding physical activity, often because gym class or sports activities are settings where these kids are very vulnerable to weight based teasing. And we even see that teasing and bullying about weight can actually predict future weight gain. And these can be really long lasting consequences. We published a study in 2017 from a longitudinal cohort called Project Eat, which essentially follows adolescents for many years. And what we found is that being teased about weight in adolescence predicted unhealthy eating behaviors and obesity and weight gain 15 years later--when those adolescents were in their thirties. And, that remains true even after we accounted for their body weight and other kinds of demographic factors. And so, we really can't ignore or underestimate the damaging impact of weight stigma on, on the quality of life for children and adolescents.
You mentioned stereotypes that are commonly thought of in this area. What sort of stereotypes are there? And what do people assume in the case of children, for example, is true of them just because of their being overweight?
Well, you know, we see some of the same stereotypes for both children and adults. Assumptions that because people have a higher body weight, they must be lazy, lacking discipline, lacking willpower. There's also stereotypes that they're incompetent, less intelligent, or sloppy. The list really goes on and on. Kind of at the root of these stereotypes are beliefs that it's a person's fault that they're overweight or obese. That they have done something personally to be responsible for their weight rather than recognizing, in the more complex, broader societal, environmental, biological factors that all play a role in determining a person's body weight.
That really creates a double whammy doesn't it. That the person is stigmatized, they are stereotyped because of their weight. But then they're also blamed for it. That's pretty powerful.
It's very powerful. And, and I think what's hard is that we live in a society that doesn't really challenge those beliefs very much. In fact, what we see from the mass media, from societal messages about weight from the diet industry, fashion industry, is that this really does come down to personal effort. When in fact we know from considerable science that that's just not the case. That body weight is a very complex issue that is caused by many different factors outside of personal control. But we don't hear those messages very often. And as a result of this societal stigma, these kinds of stereotypes remain very prevalent.
Let's talk about adults. So in what areas of life does weight based bias and discrimination affect people who suffer from these issues?
Well, certainly for adults, we see that weight bias occurs in really most societal settings and areas in life. There's considerable evidence of weight bias in employment settings where people who have a larger body size, face weight discrimination at essentially every stage of the employment cycle from being hired to getting fired. And there's evidence that that students and college students as well face weight bias in educational institutions. And that can be in the form of differential or unfair treatment from educators having lower expectations of students compared to thinner students. But you know, one of the other settings where we see a lot of documentation of weight bias is actually in health care by healthcare professionals. And, weight bias has been demonstrated from primary care providers, from cardiologists and nurses, dietitians and medical trainees, mental health professionals, you name it. And again, this kind of includes the same stereotypes that we just talked about.
Views that patients with obesity are lazy or lacking control, are to blame for their weight or noncompliant with treatment. And, this is really concerning because weight bias from health care providers can really impair quality of health care for patients. We know, for example, that some physicians spend less time in their appointments with patients have a larger body size. They give them less education about health. They're more reluctant to perform certain screenings. They talk about treating patients with obesity as being a greater waste of their time than providing care to thinner patients. And we know that patients seem to be aware of these biases from providers and that can really contribute to patients avoiding health care because they just don't want to repeat those negative experiences of bias. And, so I think this all underscores that no one is really immune to weight bias in our society. That negative stereotypes and stigma related to weight are really present across major societal institutions of healthcare and employment and education, which means that people are really vulnerable to mistreatment in multiple domains of their life.
So it sounds like it's the kind of thing people are living with every day of their lives because they're intersecting with one of these systems: education, employment, medical with medical systems almost continually all the time. And you also mentioned that the way people are portrayed in the media is a real issue here. Can you explain more about that?
Absolutely. So, you know, the media is a very influential and pervasive source of weight bias. And, our research as well as the research of others has looked at the ways that people with obesity are portrayed in the media and what we see is it is very negative. So for example, entertainment media like TV shows and movies, characters who have a larger body size are consistently portrayed in ways that really reinforce negative stereotypes as being lazy or glutinous or sloppy or a target of humor or ridicule. In the news media, this comes across a little bit differently where we see stigmatizing visual portrayals of people with obesity. So for example, the types of images or videos that accompany news reports about obesity are often very stigmatizing. And, we've done some experimental studies looking at this where we show people realistic news reports about obesity, accompanied with either stigmatizing or respectful positive images of people with obesity.
And what we see is that when people see those negative stigmatizing images, it worsens their weight bias. And we also find in our research that people don't want to see those stigmatizing images. They want to see respectful non-stigmatizing portrayals of people of diverse body sizes. But that's not what we really see in news coverage. I think what's getting even more complicated with media now is we've got social media here in the mix. And we have seen evidence of weight bias through things like fat shaming in Twitter and on YouTube. And it's unfortunate that social media has kind of become a platform for disparaging comments about people because of their weight. And it's not just adults being targeted through media. I mean these issues are also present in youth targeted media and children's TV shows and social media that appeals to youth. And so I think this is really a huge problem because again, these media messages really reinforce and contribute to broader societal weight bias. And that's difficult to shut down, especially when it's happening online. And you know, again, if we bring this back to kids, there's research that shows that the more media that youth are exposed to the higher weight bias they have. And so the influence of weight of media is really real when it comes to weight bias.
Speaking of this, you see more stories about people challenging the weight shaming that's occurring in social media. Do you think that's helping?
I do. I think even compared to 10 years ago where there was a lot of negativity, we didn't see as many people challenging or coming out and pointing out and bringing awareness. And I think that has changed and I think that there are some benefits of social media because, as much as it's a platform for some of this negativity, more people are calling it out in a way we really weren't seeing before. And so I think that's an important piece of progress. I think that we still need to sway it so that there's more positive than negative, but it's certainly a step in the right direction.
I know there's some research suggesting that familiarity with a stigmatized group will help reduce stigma because you know people as people and can learn more about their good qualities. And with two thirds of American adults now overweight or obese and the same being true for a third of American children, you'd think that almost everybody would have lots of familiarity with people who have obesity. Wouldn't this reduced bias?
I think that's a good assumption to make based on evidence that we've seen with others, socially stigmatized groups. But you're right that so many people in our society now are struggling with either overweight or obesity that we would expect bias to be much lower than what it is. And in fact, we're not seeing it reduce in the same way that we've seen other reductions. And you know, I think that's due to a couple of reasons. I think first is that we still live in a society that has very strong ideals when it comes to thinness. And thinness has come to symbolize values of hard work and discipline and attractiveness and desire. And unfortunately the converse of that thinking is that people who aren't thin are lacking in those traits and characteristics. And those thin ideals are still heavily perpetuated in the media and by the diet and fashion industries.
So that's one contributing factor. I think another real contributor is this idea of personal responsibility that is still, common in kind of the societal thinking when it comes to body weight. And, that notion of personal responsibility isn't getting challenged enough. And that's not to say that that personal behavior isn't important when it comes to body weight, but it's only one piece of a very complex puzzle. And if we only focus on that piece, which is typically what the messaging is, we're not going to address it and we're not going to be able to reduce stigma. I was just going to say that I think, the other contributing factor here is that from a policy perspective, we live in a country--and this is true for other countries in the world as well--where it's essentially legal to discriminate on the basis of weight. And we don't have policies prohibiting weight discrimination and I think that really sends a message that this form of bias is tolerable. And so those are some main contributing factors I think to why we see weight stigma remain present and in some cases pervasive in our society. And those are kind of large areas to tackle to try to reduce it.
You mentioned before that weight bias and stigma can have a negative effect on an individual's mental health, including things like depression, which in turn can lead to further reading and exacerbated weight related issues. So this really counters, doesn't it, the assumption that some people have that weight stigma is good because it puts pressure on people to lose weight. Is that pretty much been debunked now?
There has been this public misperception for quite some time that somehow stigma will motivate people to lose weight or provide an incentive to lose weight. And I think, again, a lot of that comes from inaccurate beliefs or oversimplified notions of personal responsibility for weight. And, what we know is that when we look at the research on weight stigma and health, that that weight stigma really does predict in a lot of longitudinal studies, weight gain and obesity over time. And there's a lot of evidence showing that weight stigma contributes to behaviors that promote weight gain, like binge eating or lower physical activity. And some of our recent research has found that weight stigma interferes with weight loss maintenance, making it more difficult for people to sustain weight loss over time. And so, yes, the evidence suggests that this is really contributing to health indices and health behaviors that promote gain and obesity.
And, and you know, speaking as a psychologist, I'll add as well that the idea that shame or unfair treatment is somehow an appropriate way to incentivize weight loss is completely inappropriate. And you know, rather than stigmatizing and shaming people as an approach to motivate improved health behaviors, we really need to provide people with support and empowerment to do that. And I think that in some ways, it highlights the fact that weight stigma is both a social justice issue but it's also a public health issue. And I think it really needs to be tackled on both of those fronts if we want to reduce this problem and, and improve people's quality of life. Fundamentally I think the bottom line is that this is about respect and dignity and equal treatment for children and adults, regardless of what their body size.