Battling Bias: Identifying, Understanding, and Overcoming the Stigma of Obesity

The subject of this blog entry is complicated yet important.  So, just a warning, this is a little longer read, but we think it’s worth the time and effort to dig in. We hope you’ll appreciate the significance and commit to reading all the way through!

The National Institute of Health (NIH) estimates that over 42% of the US adult population has obesity (having a BMI 30 or above), and almost 20% of children ages 2-19 have obesity (NIH).  While the scientific and medical understanding of obesity as a chronic disease has grown in recent decades and more and more treatments are becoming available, obesity bias is still alive and well every day, all around the country.

The obesity epidemic has become so significant that if things don’t change soon, there will be more individuals with obesity in our country than those without.  So, this is an issue that affects everyone, not just those who struggle with weight.

“What exactly is obesity bias?”

Obesity bias occurs when a person with obesity is judged by others solely on their weight.  The judgments almost always have negative connotations: being lazy, unmotivated, uneducated, unintelligent, entitled, economically poor, having poor character, etc.  The bias can occur in many different settings and on many different levels including the personal level, in families or other close groups like work or church, in the community like restaurants and venues, in medical settings like hospitals and clinics, and at a systemic level like insurance companies, health systems, and government entities.  Obesity bias isn’t always about direct bullying or criticism but can also involve indirect exclusion or demonstrated indifference.

For people living with obesity, the bias is not difficult to find because it happens daily all around us. Obesity bias becomes part of a vicious cycle that promotes victimization, marginalization and compounds the obesity epidemic as a whole. 

“Do I have an obesity bias?”

Sometimes having a bias is completely subconscious, but the underlying attitude shows itself in our everyday habits.  Even people with obesity can have obesity bias, simply because that’s what has been learned throughout our lives.  The first step in helping to correct a problem is first by acknowledging its existence, and then by learning and growing.

This link to a Harvard University test will help evaluate if you have an implicit weight bias.

“What are some examples of obesity bias?”

Most people who are living with obesity regularly experience both covert and overt weight bias. Overt bias would be name-calling or direct bullying about a person’s weight or behavior such as, “You wouldn’t have so much trouble sitting in that seat if you weren’t so fat.”  Covert bias is less direct and more subtle, but its effects may actually be more damaging than direct statements. Because covert bias is more subtle, it can often go unnoticed and is therefore so often just allowed to pass.  Hopefully some of the information presented here will help everyone to become more aware and react appropriately.  These are real-life examples experienced by real patients.  

Personal bias

  • A person with a binge eating disorder having a rough day checks out at a grocery store. The clerk comments, “Wow you’re buying a lot of these, so you must REALLY like them,” and “You must have a lot of kids to feed with all these snacks.” The clerk may have intended to make harmless small talk. But these comments cut deep and caused a lot of resentment in the customer. The positive note here is that she later wrote a letter to the grocery store ownership to help raise awareness.  
  • A person with morbid obesity is enjoying lunch at work when a co-worker says, “How many calories are in that meal?” This sounds like a straightforward question, but it’s not. The tone of the question and the setting (in the lunchroom in front of several co-workers) tell the person with obesity that It’s loaded with judgment and negativity.  What she hears is, “That’s too many calories for you.” She now eats alone in her office to avoid further judgment and questions and tells herself this is what she deserves.

It’s apparent that the public needs to learn that making comments about a person’s nutritional intake is totally inappropriate and can lead to an emotional, self-destructive binge (even if it’s unintentional).  It can lead to even lower self-esteem, loneliness, and isolation – all of which can worsen obesity.

If someone asks you questions or makes comments that make you uncomfortable, it’s ok to JUST SAY SO! You could even turn it around on them and respond, “Why do you ask?”  This could be an opportunity for education and for challenging invasive questions and judgmental comments.

Group bias

  • A person with obesity is excited to attend an upcoming family barbeque. She calls the host ahead of time to request to bring some chicken breast to put on the barbeque to have instead of the brisket everyone else would eat (along with mac and cheese, potato salad, potato chips, and ice cream).  The reply from the host (her own uncle, who also has obesity) was, “I am not cooking something special for you just because you’re always on a diet. Just eat smaller portions.”  He made further comments to his niece at the party that made her feel self-conscious and guilty for her request, and he even plopped a big portion of beef brisket on her plate when she specifically requested not to have any.  Even when the niece made extra effort to include herself in the family gathering, she did not find the support from her family that she needed.  Instead, she was singled out and embarrassed.
  • A dynamic sales manager plans a team bonding exercise at a local adventure park.  To help his team get over their fears and professional barriers, he arranges for each employee to take a turn on a zipline.  A new hire on the team who has obesity immediately looks at the adventure park’s website upon receiving the invitation and notes there is a 250-pound weight limit on the zipline. The employee’s weight was about 100 pounds over the limit, so he chose to call in sick on the day of the event because he was too embarrassed to point out the issue to his boss. As a newer member of the team, he did not feel he had enough rapport with the others to speak up.  As a result, he spent his “sick” day feeling very defeated and depressed, staying at home alone while he consumed about 5,000 calories. The manager either didn’t know about the weight limit or did know but decided to schedule the event anyway.  Whether it was intentional or not on the part of the manager, the impact on the team and on the individual employee was the same either way. 

While these two scenarios are different, the outcome for each is the same – the person with obesity feels isolated, unloved, worthless, guilty and deeply shamed.  But, they aren’t the only ones who miss out in these situations. These groups have normalized the behavior by not commenting or taking some corrective action.  They may also miss out by failing to include a valuable member of the group in their gatherings.  People with obesity need to have allies in their lives who recognize these experiences and help validate what the person with the obesity feels. Because people with obesity have been conditioned to believe that their extra weight is their fault, it becomes very difficult for them to set boundaries and create greater access for themselves, by themselves. In only takes one person in the group to speak up and say, “That’s not ok to say,” or “let’s find a solution that meets everyone’s needs.”  

Community Bias

  • A woman with obesity goes to the gym three days a week to work on her fitness. She works with a trainer once a week and goes on her own the other 2 days.  She sees many of the same people each time but tends to keep to herself, listening to music and following the routine her trainer gave her.  At least once per week, one of the other gym patrons gives her “helpful suggestions” about her work out like, “you could really burn more calories on that other machine,” or “you should try increasing the incline.” Now, it’s true these suggestions may just be part of gym culture and “pumping iron.” However, nobody suggested to a person with a smaller body that they are doing their workouts wrong or not intensely enough.  It’s not unusual for people with obesity to feel singled out or watched at the gym, based on the assumption that larger bodies can’t exercise properly. 
  • A local Catholic high school sends out to all families their school supply list, which includes items for student uniforms.  A rising freshman student with obesity goes shopping with her mom, only to find out the store has no uniform sizes available to fit her.  There are about six other students’ families shopping that day who saw and heard what happened. The student’s mom ordered the uniforms while the student fought back tears of embarrassment.  The uniform wouldn’t arrive for another two weeks, and the school supply list noted that if the uniform’s received by the first day of school, the student must wear plain navy pants or skirt and a white collared shirt.  During her first two weeks at school, the student had to wear the same navy sweatpants (the only navy pants that would fit her) and a white shirt from her dad’s closet (because the only white shirts she had were t-shirts).  Over those next two weeks, the student experienced staring, snickering and teasing. A teacher in one class called out to the student as she walked toward her seat, “Where is your uniform, young lady?” The whole class burst into laughter. The student mumbled to her teacher that it was the only pants that would fit her and squeezed into her desk wishing she could disappear.

In each situation, the person with obesity is marginalized because their bodies don’t conform. In a perfect world, they would be able to easily speak up for themselves and address the comments or treatment in the moment. But it’s not easy when they are feeling defeated, alone, and unworthy.   True inclusion requires action from everyone involved in the community.  If even one person were to speak up or step in, then each person would feel included and treated fairly and the overall negative attitude against obesity wouldn’t persist as it has.  

Systemic Bias

  • A person with obesity is at the airport taking her turn through the TSA screening. The x-ray screening equipment detected areas of “density,” and she was told that she must be patted down all over her stomach area. All of this took place without much dignity or privacy, as everyone in the security area observed her being singled out.  Once she got through screening and to her flight, she was required to purchase a second seat and was given a seat belt extender for the trip. (* this person did note that the airline ended up refunding her for the extra seat since her flight was not full.) 
     
  • A major regional health system opens a medical weight loss clinic in a busy outpatient building.  The clinic schedule quickly fills up, and eventually the wait list grows to almost 2,000 people.  Despite the clinic’s popularity, the health system declines year after year to fulfill requests from the clinic to provide additional resources such as providers, staff and space to meet the enormous demand.  Even with these constraints, many patients have great success with the anti-obesity medications prescribed through the clinic.  Unfortunately, however, for health system employees, all  of the FDA-approved anti-obesity medications are excluded from the employer’s health plan. Not only did the health system fail to meet the demand from the community, but the overall treatment exclusion for its employees only serves to reiterate the bias.

With the problem of obesity continuing to grow in the US, systemic bias as is described here affects everyone.  It means that our current systems no longer work for the “general public,” so we the public must work together on improving them and demanding more inclusivity in meeting public needs. 

Medical Bias

  • A person with obesity goes to a new primary provider for their first check up and physical exam.  The medical assistant (MA) is unable to get an accurate blood pressure reading because the cuff is not long enough to fit her arm.  Each time the MA inflates the blood pressure cuff, the patient experiences pain, embarrassment and concern.  The MA tells the patient they are going to look for another cuff but never returns.  The physician enters and proceeds with the exam without a blood pressure reading.  At the end of the visit, the patient asks how her blood pressure will be measured. The provider advises the patient to lose some weight since this will help improve blood pressure. The patient never got an accurate blood pressure reading and did not make a follow up appointment.
  • A woman with obesity goes to her local hospital for a routine screening mammogram. Having just turned 40, the woman was nervous about the test but proud of herself for prioritizing her recommended health screenings.  In the waiting room, she sees all the other women wearing their pink gowns with a breast cancer ribbon print all over.  The woman with obesity is given a very large, masculine, grey gown, and even that was a tight squeeze for her.  She fought back tears in the waiting room while she held her gown closed, feeling like everyone was noticing her gown and her body. Because all the women there had observed the situation, she felt so conspicuous and embarrassed that she vowed to herself to never return to that clinic again. That was her first and last mammogram.
  • Two physicians were having a medical discussion about nutrition.  One of the physicians by most standards would be considered “fit and healthy,” and he was proud of his discipline in practicing healthy lifestyle habits.  The other physician, who happened to have a board certification in nutrition in addition to her other medical training, had a personal history of obesity and had recently lost 110 pounds. She very bravely spoke up and explained to him that after many years of trying to lose weight by changing and intensifying her habits, she had the opportunity to start taking a GLP-1 anti-obesity medication, and only then did she finally see her weight reducing.  In addition to losing weight, the medication also helped her feel and perform better because she felt like her metabolism corrected, giving her a lot more energy and stamina.  She further explained that her identical twin sister (who is also a medical provider!) had very similar struggles with weight for decades.  After hearing her describe her experiences, the other physician explained very honestly that until this discussion with his colleague, he had always viewed “obese people” as lacking discipline. When he would prepare for his patients, he would “roll his eyes” if he saw that the patient had a BMI above 30, deciding that they were too lazy to lose weight. He further believed that bariatric surgery or taking anti-obesity medications was “the easy way out.”  What he understood AFTER that discussion with someone who he considered to be a highly intelligent and disciplined physician was that people with obesity DO work very hard! He thanked the fellow physician for the discussion, since his own daughter also had trouble with her weight.  He left the discussion with a new perspective on obesity and how to treat it.

The issue of medical bias is EXTREMELY important, because it can literally be life-threatening.    The person with obesity not only feels emotionally isolated, but they are also excluded from readily receiving important screenings either because they are fearful or embarrassed, or because the facility and equipment can’t accommodate their body size.  The fear and embarrassment may lead the person with obesity to medical avoidance due to the general perception that they will not be taken seriously, be mistreated in some way, or will simply be blamed and dismissed because of their weight. In the end, the person with obesity may frequently miss out on important care, putting them at an even greater risk than is posed by the obesity itself.

Just like this last scenario with the physicians, it’s apparent that obesity bias can COME FROM anyone, and it can HAPPEN TO almost anyone (including a physician!).  What is also very apparent from these examples is that ONE conversation, ONE person, ONE moment CAN make a difference in someone’s perspective and in their attitude about obesity as a disease.  With a new perspective, each of us can be kinder to the next person we see struggling with obesity. We can speak up for ourselves and get the care we need and deserve.  Our care and concern for each other might make the difference down the road for another person who feels alone in their struggles with obesity. 

“In a world of growing social justice, why is there still so much obesity bias?”

Obesity bias still exists because the past misconceptions and misunderstandings about obesity are so imbedded into our society that the resultant attitudes have persisted.  Physicians and other providers have improved understanding and acceptance of obesity as a chronic disease, but their ability and resources to treat have limited them from improving the problem in any statistically significant way.

Another major reason that obesity bias still exists today relates to the media and the messages that are being communicated. Because people with obesity tend to shy away from medical providers, they are reliant on social media and other outlets for information and advice.  “Diet culture” continues to promote cycling through multiple restrictive programs, sells products that don’t work and sends messages that if you’re not losing weight then you are to blame.

There is also the issue of unrealistic visual body image standards.  If the public is constantly receiving the message that smaller bodies equal happiness, success, and acceptance, then the pursuit for the smaller body will be forever persistent.

“What can I do to reduce obesity bias?”

Real and meaningful change will occur with everyone’s help, but it won’t happen with the flip of a switch. Rather, it will take small efforts from a lot of people to finally change the direction of the current situation.  Following are a few areas that could use some focus, attention and action.

Words Can Hurt

The first thing that every person can do is to change their language. Prioritize the person rather than their condition.  For example, instead of referring to a patient as “an obese male,” describe him as “a male with obesity” or a “man living with obesity.” Again, obesity is a medical condition and not a personality trait, so how we think about and refer to people who have obesity can greatly change overall attitudes and how people with obesity feel about themselves. We would not refer to someone as “the kidney guy,” or the “hypertension woman,” so we should have the same consideration for patients with obesity.

Learn and Grow

As was previously mentioned, there is a lot of growing research about obesity. Just be sure that what you read, watch and absorb is credible and neutral (and not JUST trying to sell something!).  Reports that are sourced from a government agency or program (like the Centers for Disease Control or the National Institute of Health) or public education institutions (universities, colleges, etc.) are generally regarded to be neutral and reliable. Here are a few suggested resources to help you get started:

Overweight & Obesity | CDC

Overweight & Obesity Statistics – NIDDK (nih.gov)

https://www.centerfornutrition.org

Be an Everyday Ally

If you see someone being treated unfairly, step in and say something. Even if you don’t stop bias from occurring, acknowledging and validating it to the person who experiences bias can be hugely impactful. If a person with obesity knows they’re not alone, they may feel empowered to stand up for themselves in the future.

For most people, if they were to see a person with a physical disability being mistreated or disregarded, the decision to step in and help would be easy. Standing up and being a friend and ally to someone with obesity should be no different.  Every human despite their conditions should be cared for and cared about. Challenge yourself to look for an opportunity in your daily life to make a difference for even one person.

Join An Organization

There are organizations that serve to educate and inform the public about obesity and support and motivate those who live with obesity.  Again, if you get information from a commercial enterprise, be mindful of the source and weigh it appropriately.  Here are some suggested organizations to get you active and involved:

www.Obesityaction.org

www.Obesitymedicine.org

www.Obesity.org

Living with obesity is not easy, and it is a complex disease to treat.  It’s complicated, and sometimes very frustrating to lose weight.  People with obesity wear their disease on the outside of their bodies.  So, if you see someone with obesity, know that they struggle every day and feel alone much of the time.  Be empathetic, be patient, and be kind.  Even paying someone a compliment or offering a hand can truly change the direction of someone’s day and even their life. 

Please, don’t make the mistake of thinking that one person can’t make a difference.