Bias, Discrimination and Obesity

Chapter 40

Bias, Discrimination and Obesity

Rebecca Puhl and Kelly D. Brownell

Introduction

It has been said that obese persons are the last acceptable targets of discrimination.^1–4 Anecdotes abound about overweight individuals being ridiculed by teachers, physicians, and complete strangers in public settings, such as supermarkets, restaurants, and shopping areas. Fat jokes and derogatory portrayals of obese people in popular media are common. Overweight people tell stories of receiving poor grades in school, being denied jobs and promotions, losing the opportunity to adopt children, and more. Some who have written on the topic insist that there is a strong and consistent pattern of discrimination,⁵ but no systematic review of the scientific evidence has been done.

Some anecdotes relevant to this issue have become highly visible. One reported by National Public Radio is that of Gina Score, a 14-year-old girl in South Dakota sent in the summer of 1999 to a state juvenile-detention camp.⁶ Gina was characterized as sensitive and intelligent, wrote poetry, and was planning to skip a grade when she returned to school. She was sent to the facility for petty theft—stealing money from her parents and from lockers at school “to buy food.” She was said to have stolen “a few dollars here, a few dollars there” and paid most of the money back.

The camp, run by a former Marine and modeled on the military, aimed, in the words of an instruction manual, to “overwhelm them with fear and anxiety.” On July 21, a hot humid day, Gina was forced to begin a 2.7-mile run/walk. Gina was 5 feet 4 inches tall, weighed 224 pounds, and was unable to complete even simple physical exercises such as leg lifts. She fell behind early but was prodded and cajoled by instructors. A short time later, she collapsed on the ground panting, with pale skin and purple lips. She was babbling incoherently and frothing from the mouth, with her eyes rolled back in her head. The drill instructors sat nearby drinking sodas, laughing, and chatting, accusing Gina of faking, within 100 feet of an air-conditioned building. After 4 hours with Gina lying prostrate in the sun, a doctor came by and summoned an ambulance immediately. Gina’s organs had failed and she died.

There are many more examples, from teachers weighing children in front of a class and announcing the weights, to doctors belittling patients because of their weight, to Dr. Kenneth Walker, who said in his nationally syndicated newspaper column that for their own good and the good of the country, fat people should be locked up in prison camps.⁵ However, anecdotes of bias and discrimination could represent isolated events and do not prove that discrimination occurs in a systematic and widespread manner. It is important, therefore, to document whether discrimination does exist. Discrimination is harmful to its victims in many ways and can have enduring effects.^7–8 With 54% of the U.S. population now overweight and 34% obese and with the prevalence still increasing in the United States and around the world, the health and well-being of many millions of people might be affected.⁹

Perhaps the first commentary on widespread discrimination toward obese individuals was offered by Allon¹⁰ over two decades ago. Since then, obesity is becoming increasingly recognized as a “social liability in Western society.”¹¹ The purpose of this chapter is to examine existing literature on this topic, with special attention to areas of major importance to well-being. Legal remedies sought by obese individuals accusing institutions of discrimination will be discussed, areas in need of further research will be noted, and conclusions will be drawn about the state of this field. This chapter is organized in sections on discrimination in areas of employment, medical and health care, education, and areas we believe are in need of additional research.

There are a number of important related topics, such as theoretical models underlying stigma, psychological processes and social origins leading to discrimination of obese people, effects of this stigma on obese individuals, and possible discrimination against obese people in social relationships. All are important and require attention but will not be addressed here because systematic review would be lengthy. Our first priority is to document whether discriminatory attitudes and behaviors occur.

Employment Settings

Hiring Prejudice

The workplace is one sphere where over-weight people may be vulnerable to discriminatory attitudes and fat bias. A number of studies have investigated weight-based discrimination in employment. The results point to prejudice, insensitivity, and inequity in work settings.

Experimental studies addressing stereotypic attitudes in employers suggest that overweight people may be at a substantial disadvantage even before the interview process begins. Experimental studies have investigated hiring decisions by manipulating perceptions of employee weight, either through written description or photograph. Participants (most often college students) are randomly assigned to a condition in which a fictional job applicant is described or pictured as overweight or average weight (but with identical résumé) and are asked to evaluate the applicant’s qualifications.

An example is a study using written descriptions of hypothetical managers.¹² Managers described as average weight were rated as significantly more desirable supervisors, and overweight managers were judged more harshly for undesirable behaviors (such as taking credit) than were average weight managers. Similarly, in a study by Klassen et al.,¹³ women students (N 216) read employee summaries of nine fictitious women employees, varying in weight and in stereotypical descriptions associated with obesity and thinness. Participants indicated the most desire to work with thin targets and the least desire to work with obese targets, although participants did not rely on stereotypical perceptions of weight in recommending harsh discipline to employees.

A study of job applicants for sales and business positions reported that written descriptions of target applicants resulted in significantly more negative judgments for obese women than for non-obese women.¹⁴ Participants (N 104) rated obese applicants as lacking self-discipline, having low supervisory potential, and having poor personal hygiene and professional appearance. In general, participants held these negative stereotypes for obese applicants for sales positions but not for business positions. Interestingly, the study’s findings were not mirrored when photographs were used instead of written descriptions of weight. The authors proposed several confounding factors to explain this outcome, such as differing applicant information accompanying the photographs, and concluded that obese applicants remain vulnerable to negative evaluations because of their weight.¹⁴

Several studies have manipulated applicant weight with videotapes. This was done over two decades ago by Larkin and Pines¹⁵ in which participants (N 120) viewed a video of a job applicant in a simulated hiring setting. The scenario involved an applicant completing written screening tests for work requiring logical analysis and eye-hand coordination. Overweight applicants were significantly less likely to be recommended for hiring than average-weight applicants, and overweight applicants were judged as significantly less neat, productive, ambitious, disciplined, and determined.¹⁵ Another study using a simulated hiring interview for a receptionist position found that the obese applicant was less likely to be hired than the non-obese applicant.¹⁶ This study was able to rule out the extraneous factor of facial attractiveness by masking the faces of both applicants.

A more recent and impressive study used videotaped mock interviews with the same professional actors acting as job applicants for computer and sales positions in which weight was manipulated with theatrical prostheses.¹⁷ Subjects (N 320) indicated that employment bias was much greater for obese candidates than for average-weight applicants; the bias was more apparent for women than for men. There was also a significant effect reported for job type; obese applicants were more likely to be recommended for a systems analyst position than for a sales position.¹⁷ Other evidence also demonstrates employer perceptions of obese persons as unfit in public sales positions and more appropriate for telephone sales involving little face-to-face contact.^{18, 19} Jasper and Klassen²⁰ instructed participants (N 135) to evaluate a hypothetical salesperson’s résumé that included a written manipulation of the employee’s weight. Obesity led to more negative impressions of the applicant and made the applicant significantly less desirable to work with. Participants who viewed the obese applicant description said directly that the obesity led to their judgments.

Excess weight may be especially disadvantageous in some settings. In a recent study of hiring preferences of overweight physical educators, most hiring personnel sampled (N 85) reported that being 10 to 20 pounds over-weight would handicap an applicant, regardless of qualifications.²¹ The authors concluded, “our hope is that these findings may serve to motivate some of these individuals to improve their health behaviors and in turn become better professional role models.”²¹

Inequity in Wages, Promotions, and Employment Termination

A comprehensive literature review by Roehling²² summarizes numerous work-related stereotypes reported in over a dozen laboratory studies. Overweight employees are assumed to lack self-discipline, be lazy, less conscientious, less competent, sloppy, disagreeable, and emotionally unstable. Obese employees are also believed to think slower, have poorer attendance records, and be poor role models.²³ These stereotypes could affect wages, promotion, and termination.

There is evidence of a significant wage penalty for obese employees. This takes several forms: lower wages of obese employers for the same job performed by non-obese counterparts, fewer obese employees being hired in high-level positions, and denial of promotions to obese employees. A study of over 2,000 women and men (18 years of age and older) reported that obesity lowered wage growth rates by nearly 6% in 1982 to 1985.²⁴

Although both obese men and women face wage-related obstacles, they experience discrimination in different ways. An analysis from the National Longitudinal Survey Youth Cohort examined earnings in over 8,000 men and women 18 to 25 years old and reported that obese women earned 12% less than non-obese women²⁵ Like studies to follow, this investigation indicated that the economic penalty of obesity seems to be specific to women. More recently, research based on earnings of 7,000 men and women from the National Longitudinal Survey of Youth indicated that women face a significant wage penalty for obesity and that obese women are much more likely than thin women to hold low-paying jobs.²⁶ Another longitudinal study following young adults over 8 years found that overweight women earned over $6,000 less than non-obese women.²⁶ Gortmaker et al.²⁷ and Stunkard and Sorensen⁴ attribute lower wages to social bias and discrimination. Obese men do not face a similar wage penalty but are under-represented and paid less than non-obese men in managerial and professional occupations and are over-represented in transportation occupations, suggesting that obese men engage in occupational sorting to counteract a wage penalty.²⁶

Experimental research indicates that obese employees are rated to have lower promotion prospects than average weight counterparts.²⁸ A recent study instructed supervisors and managers (N 168) to evaluate the promotion potential of a hypothetical employee in a manufacturing company with one of eight disabilities or health problems, including obesity, poor vision, depression, colon cancer, diabetes, arm amputation, facial burns, or no disability.²⁹ The obese candidate received lower promotion recommendations (despite identical qualifications) than a nondisabled peer and was rated to be less accepted by subordinates than the other promotion candidates.

Little research has addressed the issue of employment benefits for obese workers. Employers may demand that overweight employees pay higher premiums for the same benefits as non-overweight employees.²³ One self-report study of 445 obese individuals found that among those 50% or more above their ideal weight, 26% indicated that they were denied benefits such as health insurance because of their weight, and 17% reported being fired or pressured to resign because of their weight.³⁰

As the work by Rothblum et al.³⁰ suggests, some obese employees perceive that they have been fired and suspended due to their weight. Legal case findings suggest that termination against obese persons can result from prejudiced employers and arbitrary weight standards.³⁰ For example, in the case of Civil Service Commission v. Pennsylvania Human Relations Commission, a man was suspended without pay because he exceeded the required weight standards for city laborers.^{31, 32} Similarly, in Smaw v. Commonwealth of Virginia Department of State Police, an obese state trooper of 9 years was demoted to a dispatcher position for failing a weight-loss program.^{33, 34} Formal employment termination cases on the basis of weight have also reached the courts. For example, in Nedder v. Rivier College, a morbidly obese woman was removed from her teaching position because of her weight, and in Gimello v. Agency Rent-a-Car Systems, an office manager was fired due to his obesity despite his excellent employment records and commendations of high performance.35, 36

Airline industry weight regulations for flight attendants have also posed problems for employees above average weight. In Tudyman v. Southwest Airlines, a flight attendant was terminated and his reinstatement was denied because his weight exceeded airline requirements.³⁷ Courts have accepted airline weight restrictions, even though most weight maximums have been arbitrarily chosen and make no exceptions for age or body frame.³⁸ Airlines have claimed that weight maximums are necessary for job performance and attendants’ health and abilities to perform duties, although physical fitness or actual tests of job-related abilities would be more appropriate standards.³⁸ Flight attendants are required to be certified yearly through evaluations of their abilities, and weight policy methods for evaluation and termination are difficult to justify on grounds other than appearance.³⁸

The existence of legal cases does not establish that weight discrimination occurs in great numbers, only that some employees believe that they have been treated unfairly due to weight. Courts will decide whether a legal basis exists for such claims, but additional research is needed to determine the prevalence of the problem, the people who will most likely be affected, and the consequences on the health and well-being of the people who experience discrimination. From the evidence presented here, it seems that discrimination does occur.

Summary and Methodological Limitations

There are multiple sources of evidence suggesting that discrimination against obese employees may be significant, and that certain occupations may be especially affected. At least some obese employees may receive inequitable treatment with respect to promotions and benefits. Additional research is needed to support these preliminary findings and to provide more confident conclusions that these are indeed real-life problems. Table 40.1 presents a general summary of topics which we believe are priorities for further research.

Several methodological limitations are also evident in this research. First, studies have primarily used written description, videotapes, and self-report measures to assess whether or not an obese person would be hired, and have done less examination of real-life hiring practices. Second, many studies have failed to address possible confounds such as age, race, and gender in attempting to examine weight-related discrimination. Third, many studies have relied on college-student samples, which may not provide an adequate understanding of hiring and interviewing processes used by employers and managers. Fourth, few studies have surveyed obese employees about their discriminatory experiences. In one self-report study, 16% of obese adults (N 55) reported being discriminated against because of their weight, which resulted in difficulties at work and in social relationships.³⁹ Additional research is necessary to determine whether the prevalence of discriminatory experiences is indeed this common.

Medical and Health Settings

Attitudes of Medical Professionals Toward Obese Individuals

Anti-fat attitudes among health care professionals, if they exist, could potentially affect clinical judgments and deter obese persons from seeking care. A number of studies have addressed this topic. A study of over 400 physicians identified patient characteristics that aroused feelings of discomfort, reluctance, or dislike.⁴⁰ Physicians were mailed anonymous questionnaires and asked to specify five diagnostic categories and social characteristics of patients to which they responded negatively. One third of the sample listed obesity as one of these conditions, making it the fourth most common category listed (among dozens of other categories), and ranked behind only drug addiction, alcoholism, and mental illness. Physicians associated obesity and other negatively perceived conditions with poor hygiene, noncompliance, hostility, and dishonesty. The authors concluded that physicians’ responses may reflect Protestant ethic values, which emphasize self-discipline, persistence in the face of adversity, and achievement—characteristics that physicians believed were low or absent in patients with conditions like obesity and alcoholism.⁴⁰ Similarly, a study of 318 family physicians using anonymous questionnaires found that two-thirds reported that their obese patients lacked self-control, and 39% stated that their obese patients were lazy.⁴¹

Another study examined attitudes about obese patients in health care professionals specializing in nutrition (N 52) and found that 87% believed that obese persons are indulgent, 74% believed that they have family problems, and 32% believed that they lack willpower.⁴² Furthermore, 88% said that obesity was a form of compensation for lack of love or attention, and 70% attributed the cause to emotional problems.

These negative attitudes are not new. In 1969, Maddox and Liederman⁴³ addressed fat biases using self-report measures among 100 physicians and student clerks from a medical clinic. Obese patients were viewed as unintelligent, unsuccessful, inactive, and weak-willed. In addition, physicians indicated that they preferred not to treat overweight patients and that they did not expect success when they were responsible for their management.

Some research has also examined perceptions of nurses. A study of 586 nurses investigated beliefs about obesity and found that patient noncompliance was rated as the most likely reason for obese patients’ inability to lose weight⁴⁴ and that ineffectiveness of weight loss programs as the least important reason for lack of success. Yet, the nurses reported confidence in giving weight loss advice regardless of the outcome and despite spending 10 minutes or less discussing weight loss with patients.

In a similar study, nurses agreed that obesity can be prevented by self-control (63%) and that obese persons are unsuccessful (24%), overindulgent (43%), lazy (22%), and experience unresolved anger (33%).⁴⁵ In addition, 48% of nurses agreed that they felt uncomfortable caring for obese patients, and 31% would prefer not to care for an obese patient at all.

These findings parallel another investigation of women registered nurses (N 107), where 24% of nurses agreed or strongly agreed that caring for an obese patient repulsed them, and 12% reported that they preferred not to touch an obese patient.⁴⁶

Older nurses had less favorable attitudes than younger nurses, and dissatisfaction with their own weight was positively correlated with negative stereotypes.

Only two studies have examined attitudes toward obesity among dietitians. One study of 439 registered dietitians showed ambivalent attitudes toward obese clients.⁴⁷ In contrast, a study examining attitudes among dietetic students (N 64) and registered dietitians (N 234) reported negative attitudes toward obesity among both groups.⁴⁸ This is an important area for further inquiry because dietitians are often in a position to influence patients’ attitudes toward food and eating.

In addition to professionals already working in the medical field, studies have also surveyed medical students regarding their attitudes toward the obese. Blumberg and Mellis⁴⁹ reported substantial prejudice by medical students toward obese patients. On characteristics of personality, humanistic qualities, body image, and qualities related to medical management, students rated morbidly obese individuals significantly more negatively than average weight persons, who were rated neutrally or positively. Adjectives thought to apply to obese patients included worthless, unpleasant, bad, ugly, awkward, unsuccessful, and lacking self-control.⁴⁹ Negative attitudes did not change after students worked directly with obese patients during an 8-week psychiatry rotation. These results support other research documenting stigma and stereotyping among students.^{50, 51}

The most recent study on practices of health professionals queried obese individuals in treatment about their experiences with physicians. The subjects were generally satisfied with their care for general health issues and their physicians’ medical expertise. They were, however, significantly less satisfied with the care they received for their obesity. Nearly one-half reported that their physicians had not recommended common methods for weight loss, and 75% reported that they look to their physicians a “slight amount” or “not at all” for help with weight.⁵²

Only one study has attempted to intervene by reducing stigma toward obese patients, this among medical students.⁵³ Before random assignment to a control group or education intervention involving videos, written materials, and role playing exercises, the majority of medical students in this study (N 75) characterized obese individuals as lazy (57%), sloppy (52%), and lacking in self-control (62%), despite indicating an accurate scientific understanding of the cause of obesity. After the educational course, students demonstrated significantly improved attitudes and beliefs about obesity compared with the control group. The effectiveness of the intervention was still supported 1 year later.

Implications of Prejudice for Health Care of Obese Persons

It is important to address the impact of negative professional attitudes on clinical judgment, diagnosis, and care for obese individuals. Several studies have indicated that obesity may influence judgments and practices of professionals. Young and Powell⁵⁴ assessed clinical judgments among mental health workers using an analog approach in which participants evaluated a case history of a patient in one of three weight conditions. The obese patient was most frequently assigned negative symptoms compared with the overweight and average weight clients and was rated more severely on a variety of dimensions of psychological functioning.⁵⁴

A more recent investigation of over 1,200 physicians (representing specialties of family practice, internal medicine, gynecology, endocrinology, cardiology, and orthopedics) indicated poor obesity management practices.⁵⁵ Physicians completed self-report surveys addressing attitudes, intervention approaches, and referral practices for obese patients. Although physicians recognized the health risks of obesity and perceived many of their patients to be over-weight, they did not intervene as much as they should, were ambivalent about how to manage obese clients, and were unlikely to formally refer a client to a weight loss program. Only 18% reported that they would discuss weight management with over-weight patients, which increased to 42% for mildly obese patients.

Similar results were reported by Price et al.⁴¹ Among 318 physicians surveyed, many referred obese patients to commercial weight loss programs with questionable success. Although the majority felt obligated to treat their obese patients, 23% did not recommend treatment to any of their obese patients and 47% said that counseling patients about weight loss was inconvenient.⁴¹

Another study suggests that physicians may be ambivalent in treating obesity. In a sample of 211 primary care physicians, only 33% reported being centrally responsible for managing their patient’s obesity, where 39% perceived their role to be cooperative to other providers.⁵⁶ Although attitudes were not reported in this study, physicians indicated that insufficient time, lack of medical training, and problems of reimbursement were difficulties in managing obesity effectively.

A final study surveying attitudes and practices of 752 general practitioners in weight management reported mixed results.⁵⁷ These physicians reported holding positive views about their roles in obesity management but underused practices that promote lifestyle changes in patients, described weight management as professionally unrewarding, and noted their most common frustrations in treating obesity were perceptions of poor patient compliance and motivation.

Negative attitudes and reluctance in physicians may lead obese persons to hesitate to seek health care,⁵⁸ although as we mention below, other factors may also contribute. In one study of physician and patient behaviors, 290 women and over 1300 physicians responded to anonymous questionnaires to determine the influence of obesity on the frequency of pelvic examinations.⁵⁹ Reluctance to have examinations increased from average weight to moderately overweight to very overweight women, where the very overweight women were significantly less likely to report annual pelvic examinations. Body image was associated with pelvic exams; 69% of women who had a positive body image vs. 55% of those who had negative body image reported obtaining examinations. Among physicians, 17% reported reluctance in providing pelvic exams to very obese women, and 83% indicated reluctance when patients were reluctant themselves. The youngest physicians were most reluctant to perform pelvic exams, and among the oldest physicians a gender difference emerged where men physicians were more reluctant to provide exams than women physicians. Considering that overweight women feel hesitant to obtain exams because of their negative body image and that physicians are reluctant to perform exams on obese or reluctant women, many overweight women may not receive necessary treatment.⁵⁹

Two other studies have documented delay in seeking medical care by obese women. One investigation of self-reports of 310 hospital-employed women (such as nurses and nursing assistants) found that body mass index (BMI) was significantly related to appointment cancellations.⁶⁰ Over 12% of women indicated that they delayed or canceled physician appointments due to weight concerns, and of the 33% of women who had discussed weight with their physicians, discussions were described as negative.⁶⁰ In addition, 32% of women with a BMI > 27 kg/m², and 55% of those with a BMI over 35 kg/m² delayed or canceled visits because they knew they would be weighed; the most common response for delaying appointments was embarrassment about weight.⁶⁰

Another recent self-report study of women (N 6891) included in the 1992 National Health Interview Survey reported that increased BMI was associated with decreased preventive health care services.⁶¹ Obese women were significantly more likely than non-obese women to delay breast examinations, gynecologic examinations, and papanicoloau smears, despite an increase in physician visits as BMI increased. The authors concluded that even when obese women have more frequent physician appointments, they seem least likely to use preventive services.⁶¹

Most available studies have assessed physician attitudes and beliefs, which may or may not affect their practice, and, other health care professionals have not been studied in detail. Research has failed to account for the fact that obese patients may delay or cancel medical appointments for a variety of reasons, such as anxiety about being weighed or disrobing regardless of how supportive health care professionals may be. Still, it is clear that health professionals share general cultural anti-fat attitudes. Considering that bias affects many of the ways individuals interact with stigmatized groups, it would be surprising if medical practices were immune.

The hope is that care for obese individuals will improve as bias decreases. Some health care professionals perceive obesity to be a social problem and systematically avoid it in their practices⁶² For those who consent to treat obese patients, removing prejudice and blame may be crucial. As Yanovski⁶³ notes, “The primary care physician who provides sensitive and compassionate care for severely obese patients without denigrating them for their inability to lose weight performs a much needed service.” Other suggested changes include recognition of obesity as a chronic medical condition, improved knowledge of nutrition and multidisciplinary treatments, familiarity with community resources, creating more accessible environments for obese persons by providing armless chairs and larger examination gowns, and treating patients with respect and support.63, 64

Insurance and Health Care Cost Obstacles

Controversies in Coverage for Obesity