Abstract
Considerable attention has been given to the behaviors that need to be changed in individuals who are overweight and obese. Much less attention has been given to the behaviors that need to be changed in health care professionals who treat these individuals. Specifically, health care professionals, similar to the general population, have been shown to engage in weight-based discrimination. The impact this may have on patients is discussed.
Obesity has reached epidemic proportions in children and adults.1,2 The need to address this disease from a preventative standpoint is clear. 3 As discussed in this issue by Meek, 4 multiple areas of health should be promoted through all periods of child development (e.g., infancy, childhood, adolescence). For example, promoting better nutrition, establishing practices that promote behavior change, increasing physical activity, and decreasing sedentary behavior have all been shown to play important roles in obesity prevention. 4 There is a clear consensus regarding the behaviors that patients need to change to promote health; however, there is a growing body of literature that suggests health care providers (HCPs) need to make changes as well.
The attitudes and beliefs that HCPs have toward patients have been shown to affect patient behaviors and overall care. 5 Weight-based discrimination and stigmatization have been shown to be a problem among HCPs. For example, patients who are obese may be viewed as less intelligent 6 or lacking motivation 7 and seen as less likely to change. 6 As a result, these patients may be given less time in consultations. 8 Because of the potential for biases to impact care, there is a clear need for HCPs to be aware of these biases and make changes in their attitudes.
Weight-Based Discrimination
Weight-based discrimination is on the rise and remains a socially acceptable form of discrimination.9-11 People who are overweight have reported being stigmatized in the workplace and academic settings. Peers and family members have reported viewing individuals who are obese as lazy, lacking will-power and self-discipline, incompetent, less intelligent, and having emotional issues.12-14 Research has also demonstrated that teachers report stigmatizing attitudes toward students who are obese. 15 Although these attitudes may be latent or unconscious, negative expectations may be recognized and internalized by obese individuals. In this way, individuals are inadvertently affecting obese children’s views of themselves.
Weight-based discrimination and stigmatization have been shown to be a problem among HCPs.
These biases have also been shown to be held by HCPs. For example, physicians,6,8,16 nurses,7,17-20 dietitians,21,22 psychologists, 23 and HCPs in general24,25 have all been shown to have biased attitudes toward patients who are obese. Specifically, HCPs rate patients who are obese as unsuccessful, overindulgent, lazy, overly emotional, and lacking self-confidence.8,24-26 Additionally, school HCPs viewed children who are obese as more emotional, less likely to succeed, and having more family problems than children who are not obese. 12 There is some evidence to suggest that these attitudes affect the care provided to patients.8,27
Internalization of Discrimination
One possible explanation for how weight-based discrimination affects the care provided to individuals is described by the phenomena called the Pygmalion and the Golem effects. The Pygmalion effect, first introduced in a study by Rosenthal and Jacobson, demonstrated that students’ academic achievements and behavior were influenced by teachers’ expectations of the students’ abilities. 28 In this seminal study, teachers were led to expect better academic performance from certain randomly selected students. At the end of the school year, students identified as “gifted” showed greater intellectual growth, as measured by a standardized test, than students in the control group. 28 In addition, teachers described the “gifted” students as happier, more curious and interesting, and being more likely to succeed in the future. 29
As positive expectations elicit improved performance by those who are perceived positively, negative expectations may similarly elicit decreased performance (ie, the Golem effect). Because society in general has negative perceptions and expectations of individuals who are obese, these individuals may begin to internalize such views by creating a self-fulfilling prophecy.30,31 For example, children who are stigmatized as being unattractive often have fewer opportunities for social interaction and social skills development. 32 This stigmatization may cause children to avoid social situations as well. Taken together, the overall lack of experiences for them to discredit this stigma further reinforces the bias that they are unattractive. In this way, stigmatization may have a lifelong impact.33,34
Additional Consequences
Many of the attitudes held toward patients who are obese may be inadvertent; however, negative perceptions and stereotypes held toward those who are overweight or obese may lead to a more direct or overt discrimination. For example, although physicians ordered more tests for patients who are obese, less time is spent with these patients.8,35 Overt stigmatization can also create adverse psychological consequences. Teasing and other negative feedback directed at individuals who are obese put them at increased risk for behavioral and emotional problems. 36 For example, obese children exhibit increased depressive symptomatology, decreased self-concept, and impaired social functioning compared with their normal weight peers. 37 Additionally, severely obese children have been shown to have poor academic performance, which may be linked with their increased risk for psychosocial problems. 38
Reluctance to Discuss Weight
Many HCPs understand the stigma and discrimination associated with being a child who is overweight and are sensitive to this issue; however, this awareness may lead to additional problems. Specifically, HCPs may be hesitant to discuss the issue of obesity with the child or the family. 39 Furthermore, there is a fear that parents will feel blamed for their child’s obesity. Based on these and other factors, HCPs may choose to not discuss weight issues with families. However, when obesity is addressed with an individual, the individual is more likely to engage in healthier behaviors than when the issue is not addressed. 40 Taking a client-centered approach that includes questions regarding the level of concern the child and/or parents have about their child’s weight may mitigate these reactions.
Conclusions
The impact of weight-based discrimination on patients should not be underestimated. Stigmatization toward individuals who are obese has been shown to increase caloric intake, 41 increase the likelihood of developing binge eating disorder, 42 increase the delay/avoidance of health care, 43 and lead to poorer weight loss treatment outcomes. 44 Steps are being taken to address this issue. Specifically, there are several interventions to reduce obesity stigma that have promising results in improving attitudes toward individuals who are obese.45-47 Some evidence also suggests that weight-based discrimination in the health care setting may be on the decline. 48 A critical step to behavioral change is awareness. By increasing our awareness of the biases and stereotypes that are held toward individuals who are obese, we can begin to change our behaviors with these individuals and create a health care atmosphere that is more conducive to supporting healthy lifestyle changes.