Attempting to Lose Weight Versus Eating More Food

Obese individuals may attempt to avoid weight stigma by engaging in weight loss attempts, especially if they believe that body weight is within personal control. Obese persons who blame themselves for being stigmatized or who internalize social stereotypes about obesity may be more likely to engage in diet attempts rather than using other coping approaches to deal with bias (103–104). A recent study of overweight and obese women demonstrated that 63% of respondents reported coping with stigma by dieting (55). Other research also suggests that obese patients may perceive reduced stigma to be a desirable outcome of extreme weight loss obtained through gastric bypass surgery (38).

In contrast, some individuals may cope with the negative emotional experiences of weight bias by turning to food. In the study of obese women mentioned above, 79% of participants reported eating more in response to weight stigma and 75% reported refusing to diet in response to stigma (55). Similar work showed that those who internalized negative weight-based stereotypes were more likely to engage in unhealthy eating behaviors, such as binge-eating (105). In overweight and obese adults participating in behavioral weight-loss treatment, greater weight stigmatization was associated with greater caloric intake, more attrition from treatment, lower energy expenditure, less exercise, and less weight loss (106). Among children, overweight girls and boys who experienced frequent teasing because of their weight were more likely to engage in unhealthy weight control and binge-eating behaviors than overweight girls and boys who were not teased about their weight (56). The relationship between weight teasing and unhealthy eating remained even when controlling for body weight of children, suggesting that the eating behaviors are not due to obesity, but to the stigmatizing encounters.

Assertive Coping Responses

Several assertive coping strategies have been identified to respond to weight bias. One example is confronting the “perpetrator” of stigma, which can include challenging another person’s behavior, often in an attempt to prevent future stigmatizing actions (107). Studies have described obese individuals making formal complaints and reacting with verbal “comebacks” or insults when stigmatized by others. Participants in one study reported that confronting the perpetrator was an effective strategy in coping with biased individuals (103). Another self-report study of overweight and obese women found that 93% of respondents reported coping with stigma by heading off negative remarks from others and 22% reported responding negatively and insulting back (55).

Another way to cope assertively with stigma is to participate in public social groups and movements that combat weight prejudice. An example of this is the National Association for the Advancement of Fat Acceptance (NAAFA), an advocacy group that challenges stigma and discrimination and promotes size acceptance (see Figure 2-2). Some work indicates that coping with stigma through asserting body acceptance protects self-image against the negative effects of bias (108). It has been suggested that social activism may be used as a coping strategy in situations in which individuals believe that their stigmatized status is unchangeable (109). Alternatively, it could be that obese individuals are more likely to cope through group-oriented actions over time, as their experiences with stigma increase. These alternative explanations need to be tested.

Figure 2-2 NAAFA: National Association for the Advancement of Fat Acceptance

Confirmation and Compensation Strategies

Instead of challenging stigma through social actions, some obese people may cope with stigma by accepting negative stereotypes attributed to them and behaving in ways that are consistent with these stereotypes. Experimental research has demonstrated “confirmation coping” strategies among obese persons. In one study, male participants were instructed to participate in casual telephone conversations with obese female participants who were not made visible to them, and males were given a photograph of either an obese or normal-weight woman whom they believed to be their telephone partner. During the phone conversations, obese female participants portrayed themselves as being similar to the stereotyped assumptions made by their phone partners and confirmed males’ negative weight-related perceptions of them (110). In another experiment, obese and non-obese women were led to believe that a male (confederate) was evaluating their attractiveness as a potential dating partner. In reality, women were randomly assigned to receive either positive or negative feedback from him. Heavier women responded to his negative feedback by attributing his criticism to their own weight, which they perceived to be a major determinant of social outcomes. Rather than challenging the confederate about his negative feedback, these women responded by confirming his negative stereotypes (83). In the little research that has examined confirmation as a response to weight stigma, there appeared to be undesirable consequences, including negative affect, depression, hostility, and vulnerability to low self-esteem (83, 111).

A related coping strategy involves attempting to compensate for negative consequences of being overweight by displaying competence in other socially valued activities (112). It has been suggested that this approach aims to prevent stigmatizing situations by increasing efforts in social interactions to achieve desired goals (113). In addition, this strategy may be used more by individuals who confront stigma for long periods of time and who feel pressured to succeed in non-weight domains in order to be accepted (114). As an example, self-report research has demonstrated that obese adults reported compensating for stigma by being assertive, friendly, and outgoing in social situations in order to improve others’ attitudes towards them (43). Experimental work has similarly observed this phenomenon. In one study, obese and non-obese women were observed in telephone conversations with others whom they were told either could or could not see them (115). In the condition in which obese women believed that they were visible to their phone partner, they evaluated themselves as more likeable and socially skilled than non-obese women. However, self-ratings did not differ among obese and non-obese women if they believed they could not be seen by their phone partner, suggesting that obese women attempted to portray themselves more positively when they believed that their visible weight might elicit negative evaluations from their partners (115).

Self-Protection Strategies

Self-protective coping strategies aim to help maintain self-esteem in the face of stigma and its negative consequences (116). Self-protection can involve: attributing others’ negative comments to their prejudice; placing less value in domains in which one’s stigmatized group is perceived as inadequate; or comparing one’s current status to others in the stigmatized group (117). Although comparing oneself to thinner persons may threaten self-esteem, making comparisons to individuals who are similarly stigmatized because of their weight may be more self-protective (116). However, research has not yet directly assessed these self-protective strategies among obese individuals and more work is needed to determine whether they can effectively buffer self-esteem.

A more extreme approach to protect self-esteem is to avoid or withdraw from social interactions as a way of preventing further stigmatizing experiences. Self-report research has demonstrated that obese individuals report using this approach to deal with stigma. In one study, overweight and obese adults reported coping with stigma by isolating themselves and by avoiding stigmatizing situations (55). Another study found that obese persons commonly reported avoiding stigmatizing social situations, such as going shopping or to the beach (114). Although people may engage in avoidance strategies to reduce distress associated with stigma, some research has demonstrated that such strategies are correlated with higher levels of distress (43). Emotional distress may increase as a result of isolation and lack of social support, which are likely outcomes of avoidance.

Although a range of responses are used by obese persons to cope with weight stigma, little research has examined these strategies, and methodological limitations of existing studies leave many questions unanswered. Research efforts are needed to identify criteria for effective coping strategies so that the impact of coping efforts on emotional well being, weight loss outcomes, and eating behaviors can be clarified, and effective coping tools can be disseminated.

Causes of Weight Bias

Cultural Transmission of Weight Bias

Little research has investigated how the denigration of obese individuals is transmitted within a given culture. However, limited evidence suggests that parents may transmit negative beliefs about obese people to their children. Parents asked to tell their preschool child a story about a child who was overweight, average-weight, or handicapped described more negative attributes and less successful outcomes for the overweight child. Parents also presented peer reactions to the overweight child as deeply disapproving (118). The widespread belief in the thin body ideal may well be associated with weight bias. Among nine-year-old girls, both parental encouragements to lose weight and peer interactions focused on body shape and weight predicted negative stereotypes about overweight people (119).

The popular media may also contribute to the transmission of weight bias and stereotypes. Heavier characters on popular television programs had fewer romantic interactions and fewer positive social interactions, and were more likely to be the targets of humor (120). In situation comedies, heavier female characters received more negative comments from male characters concerning weight than non-overweight characters; they also received stronger audience laughter, including both live and “laugh-tracked” laughter (121). Content analyses of popular television shows and films for both adults and children have found that overweight characters are frequently portrayed negatively as targets of humor and negative comments (122), and as unattractive, unintelligent, unpopular, and aggressive (123–124). More television viewing among 1st–3rd grade boys was associated with more negative stereotyping of overweight girls (e.g., lower endorsement of beliefs that overweight girls are nice, smart, clean, tell the truth, and have lots of friends) (125). Similarly, the more time 10–13-year-old children spent watching television, reading magazines, and watching television, the more negative were their reactions to obese boys and girls (126). On the other hand, one investigation found that lengthy negative portrayals unexpectedly decreased self-reported weight bias, but this finding might have resulted from the demands of the experimental situation (127). More research is needed to examine the effect on adults of negative media portrayals of obesity.

Belief in the Controllability of Weight

The most widely researched theory of the maintenance of weight bias in today’s society is attribution theory, which posits that obese individuals are disliked because they are blamed for their condition. Thus, obesity may differ from other group categorizations based on ethnic group, sexual orientation, or physical disabilities, in which group members’ status or condition is attributed to forces beyond their control. Obese individuals may therefore be more subject to overt stigmatization and discrimination relative to other stigmatized groups.

As discussed below, negative attitudes toward obese people are correlated with beliefs about personal responsibility for weight (63), though interventions to change the beliefs about the controllability of weight have not been consistently successful at increasing participants’ liking of obese persons. Reliable and well-validated measures of weight bias have included subscales assessing the extent to which respondents blame obese individuals’ behavior or willpower for their weight. Responses to these subscales were correlated with dislike and disparagement of obese individuals (7–8). Similarly, a measure of weight controllability (128) was highly correlated with a measure of negative attitudes toward obese people (9). A manipulation that increased weight controllability beliefs by showing participants before and after diet advertisements also had the simultaneous effect of increasing weight bias (128).

Belief in a “Just World” and “Beautiful Equals Good”

The “just world belief” is the notion that what leads obese individuals to be disliked is the belief that people get what they deserve in life. This belief may lead to the conclusion that if people are afflicted with a problem such as obesity, it is because they have done something to deserve it. Limited research has examined this belief in relation to weight bias. For example, belief in a just world and a social ideology of blame (e.g., the tendency to blame individuals for their poverty) were positively correlated with weight bias (7). The “just world belief” may serve an organizing function by allowing individuals to view their environments as predictable and within their control.

Similarly, the attribution of positive characteristics to attractive individuals has been labeled the “beautiful equals good” stereotype. A meta-analysis by Eagly and colleagues found that favorable personality traits and life outcomes were ascribed to attractive people more often than unattractive people (129). Considering the inverse correlation between weight and attractiveness judgments (130–131), and the widespread acceptance of the thin body ideal, the “beautiful equals good” bias could account for the prevalent negative attitudes toward obese individuals.

Changing Weight Bias

To improve the lives of overweight and obese individuals, strategies to reduce weight bias must be identified and implemented. Although it is sometimes feared that reducing weight bias might discourage efforts to reduce obesity, there is little evidence of this and some evidence to the contrary. For example, experiences of weight bias are associated with binge-eating, refusal to diet (105), and avoidance of physical activity (61–62). Despite research documenting weight bias by multiple sources, few published studies have specifically attempted to reduce stigma and negative attitudes toward obese children and adults. Three bias-reduction strategies that have received attention in the literature are highlighted here. These include methods to change attitudes by addressing attributions about the causes of obesity, evoking empathy toward obese individuals, and changing perceptions about the normative acceptability of weight-based stereotypes.

Changing Blame Attributions

In North American society, values of individualism, self-discipline, and personal control are salient. These values are often applied to body weight, which leads to perceptions that the onset and reversibility of obesity are within personal control, which may in turn increase blame toward obese individuals, as discussed previously. For example, the extent of perceived controllability of obesity was positively correlated with the degree of negative stereotyping toward obese individuals (63). Thus, attributions about the causes of obesity may be especially important to consider in attempts to reduce weight stigma.

Experimental research has specifically attempted to reduce weight stigma by manipulating perceptions of the causes of obesity. Among samples of adults, two studies demonstrated improved attitudes toward obese people by providing information that emphasized the biological, genetic, and non-controllable contributors to obesity (7, 105). However, other work examining implicit anti-fat attitudes found that informing participants that obesity is primarily due to genetic factors did not lower bias, even though providing information that obesity is caused by primarily behavioral factors (such as overeating) led to higher bias (132). These results demonstrate the persistence of weight bias and the ease with which it can be exacerbated. A promising recent intervention randomly assigned health service students to one of three tutorial courses, one focusing on uncontrollable causes of obesity (genes and environment), one focusing on controllable causes (diet and exercise), and a control condition on alcohol use. After each multi-week course ended, implicit bias had increased among the diet/exercise students, and both implicit and explicit bias decreased among the genes/environment students (133). This study suggests that training in the uncontrollable causes of obesity can reduce stigma, especially when the training is provided in an intensive format where participants are motivated to master the material (i.e., by course grades).

Additional research in this area has examined attributions about obesity specifically among youth. For instance, experimental work demonstrated that female adolescents evaluated an overweight peer more positively when the peer’s excess weight could be attributed to an external cause (such as a thyroid disorder) than when no external cause was provided for being overweight, which only increased negative evaluations of the peer (134). In a similar study of adolescents, more positive ratings were ascribed to an obese peer (who was viewed in a video) whose excess weight was attributed to a thyroid disorder compared to an obese peer whose obesity was not explained, and who was stereotyped as being less disciplined, more self-indulgent, and less popular (135).

Among elementary school children, results are similar. In one study, students were less likely to blame an obese peer for being heavy if they were provided with information suggesting the obese individual had little responsibility for her obesity, although this information did not change their liking of the peer (136). Similar work demonstrated that students in grades 3–6 attributed less blame to an obese child whose weight was attributed to external (e.g., medical) causes. Although this information had a positive effect on attitudes among younger children, it did not affect older children, who displayed even more negative attitudes toward the obese peer (14). In another experiment, children in 4th–6th grade were randomly assigned to an intervention group that viewed a brief presentation about the uncontrollability of body size or to a control group that participated in normal classroom activities (137). Students in the intervention group reduced the amount of personal control that they attributed to obesity, but did not alter their negative stereotypes about obese individuals compared to children in the control group.

Finally, even among preschool children attitudes may be affected by attributions of causality. A study of preschool children found that those who believed that weight was within personal control expressed more negative attitudes toward obese individuals (138). This is the first study to demonstrate that causal attributions are associated with negative stereotyping of obesity in such young children.

Taken together, this line of research suggests that attributions about the causes of obesity may be important to target in efforts to reduce weight stigma. However, more work is needed to determine whether, and to what extent, this approach leads to true attitudinal change. It may be that beliefs about the causes of obesity are amenable to modification, but that negative attitudes are more resistant to change using strategies that manipulate attributions of causality.

Evoking Empathy

Attempts to reduce weight stigma have also included methods designed to evoke empathy for obese individuals. Three studies have tested this approach with mixed results. In the first, adult participants read stories of first-person accounts of weight-based discrimination against obese persons that were designed to evoke feelings of empathy (132). This did not result in lower bias among participants compared to controls. The authors hypothesized that reading the empathic stories may have reminded participants of negative stereotypes associated with obesity, which served to reinforce existing bias.

In the second study, women were primed (through random assignment) to view either a video portraying obese persons talking about the discrimination they face (empathy-evoking condition) or a control video showing non-weight-related images (127). Participants then watched either a video portraying obese persons counter-stereotypically and positively (e.g., as competent) or a video portraying obese persons stereotypically and negatively (e.g., as clumsy). Overall, levels of weight bias persisted despite the video interventions, although there was a surprising trend for the negative (stereotypic) video to be associated with reduced bias in some domains.

A third investigation attempted to reduce weight stigma among medical students, who were randomly assigned to a control group or an educational intervention that incorporated videos to induce empathy, written materials, and role-playing exercises (139). Following the educational course, students demonstrated significantly improved attitudes and beliefs about obesity in comparison to the control group, and the effectiveness of the intervention was still present one year later. More work is needed to compare this approach to other bias-reduction methods and to examine the effectiveness of the strategy in combination with other approaches.

Changing Perceived Social Consensus

Another avenue for stigma reduction is a “social consensus” approach to attitude change. This framework proposes that stereotypes are a function of perceptions that one has of other people’s stereotypical beliefs and attempts to alter negative attitudes by changing perceptions about the normative acceptability of beliefs. This approach has improved attitudes toward ethnic minorities (140) and was recently applied to weight stigma in a series of experiments in which participants completed measures of self-reported attitude towards obese people prior to and following manipulated consensus feedback depicting the attitudes of other students (141). In a first experiment, university students who received favorable consensus feedback (indicating that peers held more favorable beliefs about obese people than they did) reported significantly less negative attitudes and more positive attitudes toward obese persons compared to their reported attitudes prior to consensus feedback. In addition, following favorable consensus feedback, these students changed their reported beliefs about the causes of obesity to beliefs that the causes of obesity were due to external, rather than personal, factors.

In a second experiment with university students, participants were more likely to improve their reported attitudes about obese people if they learned about favorable attitudes about obese people from an in-group source they identified with and belonged to (Ivy League students) compared to an out-group source (community college). The third experiment involved five experimental conditions comparing the social consensus approach to other methods of stigma reduction, such as providing information to students about the causes of obesity. Participants’ perceptions of others’ attitudes again significantly affected their own reported attitudes and their beliefs about the causes of obesity. Providing information about the uncontrollable causes of obesity and fabricated scientific evidence about traits commonly perceived to be characteristic of obese people also changed attitudes. Of note is that the findings demonstrated that providing information about the causes of obesity was not required to improve attitudes and that perceptions of others’ attitudes about obese people is a new and effective method to modify attitudes.

These findings indicate that learning about the unbiased attitudes of others can be influential in understanding and improving attitudes toward obese people and that addressing perceived normative beliefs may be an important target for stigma reduction efforts. It will be important to determine how to use and disseminate a social consensus approach in real-world settings and to identify the most effective methods of increasing awareness among members of valued social groups of favorable beliefs toward obese individuals. Interventions might present people with favorable attitudes about obese persons by valued individuals in a context in which tolerance is perceived to be desirable, such as in schools and medical facilities.

Conclusions and Future Research Directions

In one of the first sources documenting personal experiences of weight bias, The Pain of Obesity, a patient recounted, “I’m terrified of being condemned by people for my weight. And yet, of course, they should condemn me …” (142). Similarly, in a moving personal account of weight bias, Johnson described what can make overweight individuals upset about discrimination (143):

“The blaming, the scapegoating, the heaping of all kinds of negative qualities on people just because of their weight—often by complete strangers who are presumptuous enough to set themselves up as ‘judges.’ People look at your size and think you are lazy, stupid, and out of control. They judge you on your size and don’t take the time to see what you have to offer.”

The stigmatization of overweight and obesity is prevalent in many settings and perpetuated by numerous sources. Obese adults and children are denigrated and discriminated against in employment, educational, and medical settings, and the sources of this stigma include peers, family members, educators, and even health professionals. More research is needed to identify individual differences and differences across cultures in vulnerability to weight bias.

The costs of weight bias, to both the individual and society, are high. Evidence suggests that impaired mood and self-esteem, and even suicidal ideation, are related to experiences of weight stigmatization. Further investigation is needed to understand the relationship between obesity and academic and socioeconomic achievement, and whether and how weight bias might mediate that relationship. Similarly, the association between obesity and health-related quality of life may be related to experiences of weight-related discrimination. Numerous coping strategies used by obese individuals to deal with stigma have been identified, and future research should continue to investigate the effectiveness of these efforts in avoiding or reducing bias and its harmful effects.

In contrast to the amassing literature on weight bias, little work has identified effective strategies to reduce it. Two contemporary methods are, however, quite promising for modifying attitudes: addressing attributions about the causes of obesity and changing perceptions of the values of normative groups. There is clearly a need for additional work to identify what elements or combination of factors are most important in efforts to maximize long-term improvements in cultural attitudes and biases towards obesity.