target="_blank" rel="nofollow" href="#ulink_5a77e85e-14d0-575c-9c06-6ecda00bf425">Figure 5.1 Ecological model of weight stigma.
Source: Modified from Cook. JE. et. al. 2014 [5].
To further highlight the prevalence and intractability of weight bias, a recent study reported that implicit (or unconscious) biases due to race, skin tone, age, sexual orientation, and disability have plateaued or decreased over the past decade [14]. The only exception to this pattern was implicit weight bias, which has continued to increase over time. The singularity of weight bias in its persistence compared to other forms of bias highlights its insidious nature and the need for concerted efforts to address it. As exemplified in the clinical vignette, complex factors such as indirect expressions of bias and the intersection of multiple marginalized identities must also be considered when examining the experience and impact of weight stigma. In this chapter, we provide an overview of the most prominent social consequences for adults and youth with obesity due to weight bias; summarize recent research on the impact of weight stigma on health, and identify promising avenues for preventing and reducing weight stigma.
Social consequences for adults
Through multiple pathways across institutional, interpersonal, and intrapersonal domains, stigma facilitates social and health inequities [15]. In this next section, we highlight two prominent domains in which weight stigma contributes to these disparities among adults with obesity: employment and health care.
Employment and wages
Experimental and epidemiological studies consistently show evidence of discrimination among adults with obesity at every stage of the employment process in the United States and abroad [16]. Estimates of perceived workplace discrimination due to weight from the National Survey of Midlife Development in the United States (MIDUS) range from 9.6 to 27.7% for women with obesity, and 4.1 to 12.1% for men with obesity [11]. Persons with class III obesity (i.e. BMI of 40 kg/m2 or above) report the highest rates of employment discrimination among both men and women.
Experimental studies find that applicants and employees with obesity, compared to lower‐weight counterparts, are perceived as lazier and less competent, conscientious, hardworking, outgoing, and likable, as well as having fewer leadership qualities [4]. These biased perceptions lead to discrimination in hiring and promotion decisions [16]. For example, a recent study in the United Kingdom sent resumés of fictional job applicants to 181 workers with experience hiring employees across different types of employment sectors and manipulated the weight and gender of the applicants [17]. Results showed that applicants with obesity, compared to lean applicants or those without photographs, were considered less suitable personnel for jobs across all job sectors, particularly for manual jobs or when the applicants were female [17].
Women generally report weight discrimination at higher rates than men [18], in part due to a lower weight threshold for women to be viewed as “overweight” [19]. Using data from three large, representative US surveys, Shinall [20] found that women with obesity (and particularly class III obesity) were less likely than women with BMIs of 18.5–24.9 kg/m2 to work in jobs that involved visible, public interaction, such as public speaking and consulting, and were more likely to work in physically demanding jobs, while no differences by BMI among men were found for job sector [20]. In addition, even after accounting for demographics and job sector, women with BMIs 30–39.9 kg/m2 suffered a 5.8% wage penalty compared to leaner counterparts, and women with BMIs ≥40 kg/m2 showed a 15.7% wage penalty [20]. In contrast, men with BMIs ≥40 kg/m2 made 7.8% less in wages than those with BMIs 18.5–24.9 kg/m2, which is less than half the wage penalty faced by women in that BMI range [20]. Overweight and obesity at an earlier age also affect future wages – even if someone has since lost weight – likely due to the lasting impact of an initial obesity wage penalty on subsequent salaries and job opportunities [19,21].
The problem of weight discrimination is not restricted to the United States. A representative study of over 3000 German adults found that perceived discrimination rates were 10, 19, and 38% among participants with classes I, II, and III obesity, respectively, and women reported higher rates of perceived weight discrimination than did men [22]. Further research from the German Socio‐Economic Panel survey of over 7000 adults found that job performance did not account for the wage gap among women with obesity, dispelling a potential assumption that women with obesity earn lower wages due to lower productivity [23]. Evidence of employment discrimination due to weight has been documented in Western and Eastern countries, including Australia and New Zealand, China and Taiwan, Canada, Africa, and multiple countries across Europe [16,21].
Studies exploring potential differences in perceived weight‐based employment discrimination by race and ethnicity have yielded mixed results. While some studies suggest that White adults face greater weight discrimination than do adults of other races and ethnicities, other studies have not found this pattern of results [16]. Regardless, there is clear documentation of weight discrimination across racial and ethnic groups [18,24]. For example, a study of over 3000 African American (AA) adults from the National Survey of American Life found that AA men (though not women) with higher BMIs reported more disrespect and condescension than AA men with lower BMIs [25]. Race and ethnicity likely interact with other participant characteristics (e.g. gender, age, socioeconomic status) in its effects on weight‐based discrimination. For example, weight discrimination may come in subtler or less overt forms for members of intersecting minority groups; minority group members may be less likely to attribute discrimination to weight versus other stigmatized identities; or they may be less likely to internalize experiences of weight discrimination to the same degree as White adults [24,26]. Investigations that take an intersectional approach are needed to clarify how race and ethnicity may or may not affect weight discrimination [26].
In addition to discrimination in hiring, promotions, and wages, workplace wellness or health promotion programs that emphasize “personal responsibility” can also perpetuate employment discrimination and create a stigmatizing work environment for employees with obesity. A series of online studies found that Amazon.com Mechanical Turk workers who reported that their workplace had a wellness program also reported a stronger belief that weight is controllable, although this effect was not found among workers with obesity [27]. Further, this study found that emphasizing individual responsibility in a workplace wellness program elicited weight‐discriminatory attitudes among employees [27]. Thus, wellness programs that emphasize personal responsibility for weight may perpetuate negative weight stereotypes and discrimination without actually helping employees with obesity feel empowered to manage their weight [27]. Greater attention to the content and structure of workplace wellness programs is needed in order to offer opportunities for employees to enhance their health without contributing to workplace weight stigma and discrimination.
Health care
Specific pathways by which discrimination can impact health are described in more detail later in this chapter. Broadly, stigmatizing comments from health care professionals, overlooking health problems unrelated to weight, and denial of care for persons with obesity represent three examples of weight‐based discrimination in health care that have adverse consequences for health [28].
A high proportion of patients report feeling judged or stigmatized by their doctors due to their weight [29]. Health care professionals and trainees across disciplines – including medicine, nursing, nutrition/dietetics, psychology, and even obesity and eating disorder specialists – report weight‐biased attitudes toward patients with obesity [4,30,31]. These biases can be explicit (i.e. conscious) or implicit (i.e. unconscious; [28]). For example, physicians report having less respect for patients with obesity, viewing them as unmotivated, and holding low expectations for their treatment adherence. Biases can be communicated to patients blatantly with derogatory comments when discussing weight, recommendations that ignore the challenges of weight loss, reluctance to perform certain types of screenings, or dismissal of other more pressing health concerns in order to focus exclusively on weight [4]. Expressions of weight bias by health