Five Minutes with… Rebecca Puhl, PhD—Taking a look at weight bias and the stigma of obesity

| September 23, 2009

Dr. Puhl is the Director of Research & Weight Stigma Initiatives at the Rudd Center for Food Policy & Obesity at Yale University, New Haven, Connecticut.

Introduction
Despite ongoing attention to the obesity epidemic, the social consequences of obesity are often overlooked. In a recent issue of the journal Obesity,[1] a study was published that documents considerable prejudice and discrimination against individuals who are overweight and obese. The study reviews over 150 studies published in the past decade and reveals that weight bias is a persistent social problem affecting obese persons in many settings and often on a daily basis. Speaking with the lead author of the report, Dr. Rebecca Puhl, who is the Director of Research at the Rudd Center for Food Policy and Obesity at Yale University, Bariatric Times addresses this important clinical concern and how it affects the patient.

What exactly is weight bias?
In general, weight bias refers to negative weight-related attitudes or beliefs that are expressed as stereotypes, prejudice, and even overt discrimination toward children and adults because they are overweight or obese. Weight bias can take multiple forms: it can include verbal comments (e.g., derogatory remarks, teasing), physical aggression (e.g., bullying), and relational victimization (e.g., social exclusion, being ignored or avoided).

How common is the problem of weight bias? Is this something that a lot of people experience?
Unfortunately, weight bias is pervasive. Our recent research examined a nationally representative sample of Americans and found that weight discrimination has increased by 66 percent over the past decade[2] and is now on par with national prevalence rates of racial discrimination.[3] Individuals who were obese confronted weight bias in multiple settings, including inequities in employment, barriers in education, biased attitudes and behaviors by healthcare professionals, and even stigmatization by friends and family members.

Public perceptions about obesity often emphasize ‘personal responsibility’ and the view that obese people are to blame for their weight…perhaps even deserving of stigma. Is it possible that weight bias might serve a positive function, like motivating obese people to lose weight?
Actually, research suggests the opposite is true. Studies show that weight bias can reinforce unhealthy behaviors that lead to obesity. For example, we surveyed over 2,400 women who were overweight and obese about their experiences of weight stigmatization and how they coped with these experiences. We found that 79 percent of individuals reported that they ate more food as a coping response to weight stigma, and 75 percent reported that they refused to keep dieting.[4] We also found that individuals who internalized weight stigma (e.g., blamed themselves for negative stereotypes) reported more frequent binge-eating episodes.[5] This is supported by considerable research (in both adults and youth) showing that individuals who experience weight-based teasing or victimization are more likely to engage in unhealthy weight control practices, binge-eating, and avoidance of physical activity. We also know from research that as the prevalence of obesity has increased over time, stigma has become worse—there’s no evidence to suggest that stigma is reversing this trend.

How much of a problem is weight bias in the healthcare setting?
Weight bias is a common experience faced by patients who are struggling with their weight. Healthcare providers are not immune to bias—several decades of research have documented negative weight-based stereotypes among physicians, nurses, dietitians, medical students, and psychologists.[1] Common stereotypes include perceptions that patients who are obese are lazy, lacking in self-discipline, have no willpower, and are nonadherent with treatment. These views lead to considerable blame and can have a profound impact on quality of life for patients with obesity. Not only is weight stigma detrimental to emotional health (e.g., increasing vulnerability to depression, low self esteem, suicidality), but it can also lead patients to avoid, delay, and cancel healthcare services because of previous (or anticipated) negative experiences with providers.

What can be done to improve the healthcare environment, and to avoid stigmatizing patients?
Providers can implement a range of strategies into routine practice to increase sensitivity and reduce bias. First, it’s important to challenge personal assumptions and stereotypes about patients who are obese. Look for examples of people who challenge weight-based stereotypes, and share these with colleagues, staff, and patients. It’s also crucial to use appropriate and sensitive language about weight. Certain words or comments about weight may be offensive to patients and can jeopardize important discussions about health. Consider patients’ previous healthcare experiences and recognize that many patients have experienced weight bias from other providers. There are also ways to improve the physical office setting. For example, make sure that patients are weighed in a private setting, on an appropriate scale, and that the patient’s weight is recorded without negative comments or judgment. Ensure that medical equipment (e.g., patient gowns, blood pressure cuffs, exam tables) are appropriately sized to accommodate large patients. These strategies can improve provider-patient interactions, delivery of care, and ultimately quality of life for patients who are overweight and obese.

Time’s up!

References
1.    Puhl RM, Heuer CA. (2009). The stigma of obesity: A review and update. Obesity (Silver Spring). 2009;17(5):941–964.
2.    Andreyeva T, Puhl RM, Brownell KD. Changes in perceived weight discrimination among Americans, 1995–1996 through 2004–2006.  Obesity (Silver Spring). 2008;16(5):1129–1134.
3.    Puhl RM, Andreyeva T, Brownell KD. Perceptions of weight discrimination: prevalence and comparison to race and gender discrimination in America. Int J Obes (Lond). 2008;32(6):992–1000.
4.    Puhl RM, Brownell KD. Confronting and coping with weight stigma: an investigation of overweight and obese adults. Obesity (Silver Spring). 2006;14(10):1802–1815.
5.    Puhl RM, Moss-Racusin CA, Schwartz MB. Internalization of weight bias: Implications for binge eating and emotional well-being. Obesity (Silver Spring). 2007;15(1):19–23.

Visit www.yaleruddcenter.org for free resources for healthcare providers on weight bias topics, including a free CME (accredited for AMA credit), free educational videos, an online tool-kit, and many scientific articles.

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