Puhl, Rebecca M. Ph.D.; Wharton, Christopher M. Ph.D.
Obesity is one of the most pressing public issues of our time, and it has changed the landscape of health care delivery and health promotion. This is no exception for fitness professionals, who are now working with overweight and obese populations more than ever before. Efforts to address obesity often focus on education about the physical health consequences of obesity and strategies to prevent these adverse outcomes. Although it is imperative to identify long-term solutions for obesity, an ignored part of this problem is the social penalty that obese individuals face, often daily, in the form of bias, prejudice, and discrimination. Weight bias is a common problem in health care settings, and it is prevalent among health professionals. Individuals who are targets of weight bias are vulnerable to a range of consequences that have a negative impact on their emotional well-being and physical health.
What exactly is weight bias? It generally refers to negative attitudes and beliefs about body weight that are expressed in the form of stereotypes, stigma, prejudice, and unfair treatment toward children and adults because they are overweight or obese. Weight bias can be displayed in multiple forms, including verbal comments (e.g., derogatory remarks, negative stereotypes), physical aggression, and social exclusion or avoidance. Thus, it can be expressed in both subtle and overt ways.
Diverse methods have been used to measure weight bias. Most commonly, self-report questionnaires are used that ask respondents to evaluate, assign adjectives to, or provide opinions and attitudes about obese persons. Commonly used self-report measures include the Attitudes Towards Obese Persons Scale (1) and the Anti-Fat Attitudes Test (2). Because weight bias remains quite socially acceptable, people are often willing to report negative attitudes on these types of explicit measures (for more information on self-report measures of weight bias, please consult http://www.yaleruddcenter.org/default.aspx%3Fid%3D76).
Experimental methods also have been used to assess weight bias. These studies typically use a random assignment of participants to one of several conditions where they view a photograph or picture of a person who is portrayed as either obese or average weight (the body weight is the experimental manipulation). Participants are then asked to make various judgments about the person in the photograph to determine if body weight differentially impacts their responses. For example, experimental research has investigated weight bias among mental health professionals by instructing psychologists to read case descriptions of hypothetical patients who had identical patient profiles and histories, but who were portrayed as either obese or average weight. Results showed that obese patients were more frequently assigned negative attributes, more severe psychological symptoms, and more pathology than average-weight patients, despite identical profiles (3).
A third method of assessing weight bias is to examine implicit associations with obesity, which is accomplished using a measure called the Implicit Association Test (IAT). This test identifies automatic preferences and bias, and has been used to study bias in a range of disciplines, including sex, race, religion, sexuality, and obesity. The IAT is a tool that demonstrates the extent to which an individual holds negative implicit associations with obese people (e.g., that obese persons are "lazy" or "stupid") and shows that it is possible to hold stereotypes that are powerful enough to operate without conscious control. To learn more about this research or to complete the IAT on weight bias, please visit the following Web site: https://implicit.harvard.edu/implicit/demo/index.jsp.
Unfortunately, many obese individuals report experiences of bias by health professionals and discrimination in facility and equipment access. An accumulation of research supports these common anecdotes. Studies demonstrate that overweight and obese individuals are vulnerable to weight bias from physicians, medical students, dietitians, nurses, and psychologists (4, 5). Even health professionals who specialize in obesity are not immune to negative attitudes (6). Types of weight bias that are commonly reported by health professionals in these studies include stereotypes that obese patients are noncompliant, lazy, lacking in self-control, weak willed, unsuccessful, unintelligent, and dishonest (4). Some research also has examined beliefs about the cause of obesity among health professionals, which may reinforce negative attitudes and bias. For example, studies show that providers have assumptions that obesity can be prevented by self-control, that it is a patient's noncompliance which explains their failure to lose weight, and that obesity is caused by emotional problems (7).
This research also extends to individuals in the fitness field. Most often, studies examine weight bias using self-report surveys that ask professionals about their attitudes and beliefs toward obese individuals. For instance, one study examined weight bias among undergraduate and graduate students majoring in exercise science (8). These students exhibited a strong weight bias and endorsed a number of negative stereotypes, including beliefs that obese persons are lazy and are to blame for their weight. Many of their negative stereotypes pertained to lifestyle behaviors, including assumptions that obese individuals eat too much junk food, have poor physical coordination, and have "no excuse for being fat." Students who believed in greater personal control for obesity demonstrated stronger weight bias and negative attitudes, such as beliefs that obese persons are lazy. These findings indicate that students in the field of exercise science are capable of expressing negative attitudes toward obese persons, and this has important implications for health promotion efforts. Not only could weight bias among fitness professionals negatively impact the professional-client relationship, it also could reduce the effectiveness of wellness services provided by these professionals.
What Consequences Do Weight Bias Have for Overweight and Obese Individuals?
The negative effects of weight bias are far reaching. Research has demonstrated that weight bias by health professionals leads to decreased use of health services among overweight and obese individuals (9). These findings are not a result of low access to care, but instead point directly to bias. When asked about the reasons for canceling, delaying, and avoiding health services, obese patients attribute these decisions to disrespectful treatment and negative attitudes from providers, unsolicited advice to lose weight, embarrassment of being weighed, and medical equipment that was too small to be functional for their body size (9). The percentage of patients who reported these barriers increased with body mass index.
Weight bias also has negative consequences for health behaviors that contribute to obesity. For example, research demonstrates that weight bias leads to unhealthy eating behaviors. Overweight youth who are targets of frequent weight-based teasing are more likely to engage in unhealthy weight control and binge-eating behaviors compared with overweight youth who are not teased about their weight (10). Prospective research has demonstrated that weight-based teasing predicted binge eating at 5 years of follow-up among both males and females, even after controlling for factors like age, race, and socioeconomic status (11).
Our own studies also illustrate a negative impact of bias on eating behaviors. We surveyed over 2,000 overweight and obese women about their experiences of weight bias and how they coped with this bias. Findings showed that 79% of individuals reported that they had coped with weight bias by eating more food, and 75% reported that they refused to keep dieting in response to bias (12).
There also is evidence to suggest that obese individuals avoid physical activity because of weight stigma. For instance, overweight youth who are victimized by their peers are less likely to participate in physical activity and physical education classes (13, 14). Other research shows that people who experience weight bias have less desire to exercise, and thus, engage in decreased levels of strenuous and moderate exercise (Vartanian, L.R., and J.G. Shaprow, unpublished data, 2006) (15).
Finally, the emotional toll of weight bias is significant. Weight-based victimization seems to have a range of negative consequences, including poorer body image, lower self-esteem, and higher risk of depression (16, 17). Perhaps most alarming is research demonstrating that obese youth who are victimized by peers because of their weight are two to three times more likely to engage in suicidal thoughts and behaviors (18).
Taken together, these findings raise concerns about the impact of weight bias within the health community. Weight bias may compromise the quality of health services provided to obese persons, lead to decreased health care use, negatively affect psychosocial well-being, and increase vulnerability to lifestyle behaviors that only further contribute to obesity. All of these factors lead to reduced quality of life. Progress clearly needs to be made so the health of obese individuals is not jeopardized further as a consequence of bias, and so people can obtain the support and health services they need to improve their health, regardless of body weight.
What Fitness Professionals Can Do to Reduce Weight Bias
The importance of creating fitness environments that are welcoming to obese persons and that promote their participation in healthy lifestyle activities cannot be understated. As stated by Heather Chambliss, Ph.D., FACSM, a research scientist in physical activity and health, "It is important that fitness and wellness services are available, accessible, and acceptable to obese persons. However, anti-fat bias and weight discrimination among exercise professionals may serve as barriers for physical activity participation for some obese individuals" (8).
There are a number of strategies that fitness professionals can implement in current practices to increase awareness of bias, reduce negative attitudes, and create a supportive environment for overweight and obese individuals. These strategies are outlined below:
1) Increase self-awarenessA first step in reducing bias is to assess personal attitudes about weight. Self-awareness is a prerequisite for change. Some questions that fitness professionals can ask themselves include the following:
* Am I comfortable training and working with individuals of all body sizes?
* Am I sensitive to the needs of my obese clients?
* Do I hold stereotypes about obese persons?
* Do I make weight-based assumptions about the character, intelligence, success, or lifestyle behaviors of overweight or obese persons?
* Do I provide sensitive feedback to obese clients?
* Do I encourage obese clients to celebrate success in healthy behavior changes, even if no weight loss occurs?
2) Consider communication styleTo facilitate positive and productive professional-client interactions, it also is useful to identify language that may unintentionally communicate weight bias. This includes assumptions or stereotypes that could be expressed in verbal interactions and nonverbal behaviors (e.g., facial expressions) with obese clients. It also includes language that is used to refer to obesity. Certain words to describe weight may be hurtful and offensive to obese individuals because of pejorative connotations, and also could jeopardize important discussions about health. For example, a study examined preferred words for describing obesity among obese individuals (19). Desirable terms included "weight," "excess weight," and "BMI" (body mass index). Undesirable terms included "fatness," "fat," "weight problem," "large size," and "morbidly obese." Because people vary in comfort levels with this topic, it may be helpful to initiate sensitive conversations with obese individuals about how they would prefer their weight to be discussed. For example, asking the client "Could we talk about your weight today?" or saying "Why don't you tell me how you are feeling about your weight at this time. What are your goals now?" can help initiate interactions that maintain respect and sensitivity when discussing body weight.
3) Create supportive fitness facilitiesThere are a number of environmental changes in fitness facilities that can make a significant difference in quality of health experiences and wellness services for obese individuals. Some of these changes are as follows:Staff
* Encourage a dress code of loose, rather than form-fitting, professional athletic wear.
* Allow for diversity of body size among staff.
* Provide or encourage attendance to specialty workshops addressing interaction with overweight and obese individuals, focusing on:
* awareness of weight bias and its health consequences
* role-play exercises to increase empathy for obese clients
* education about the complex etiology of obesity
* training on exercise prescription for obese individualsEquipment
* Ensure availability of equipment usable by overweight individuals.
* Provide sufficient space between equipment throughout the fitness area.
* Ensure that seating areas (e.g., entrance area, waiting rooms, locker rooms) provide an atmosphere appropriate for patients of all sizes. This includes having sturdy, armless chairs, wide doors, and large bathrooms that accommodate overweight and obese clients.Techniques
* Ensure that scales are sufficient to accommodate obese clients.
* Depending on the population served, scales with a maximal capacity of 200 kg (440 lbs) will be sufficient for most settings; however, scales are available that can accommodate up to 270 kg (595 lbs).
* Ensure that weighing occurs in a private setting, and that the individual's weight is recorded free of judgment and commentary.
* Encourage sensitive administration of other assessment techniques.
* When interviewing clients for the first time or assessing progress, be mindful of appropriate language when asking questions about weight (as discussed above), elicit clients' feedback, listen to their statements and concerns, and communicate support.
4) Reduce bias through educationAn important tool for changing attitudes also can come from education. Both educators and students in exercise science and related health fields can take steps to increase awareness of weight bias and reduce the prevalence of this problem in young fitness professionals. Suggestions include the following:Educators
* Develop curriculum focused on obesity etiology, treatment, and prevention.
* Create specific sections on exercise testing and prescription for obese populations (include information on the impact of overweight and obesity on functionality, fitness, and performance).
* Address weight bias or sensitivity training as a standard component of health curriculum.
* Incorporate laboratory sections to practice administration and alteration of assessment techniques in a sensitive manner.Students
* Seek training and other opportunities within fitness facilities that allow for a diversity of experiences with a wide variety of populations.
* Look for opportunities within your professional organizations to learn more about working with clientele of various body types and functional limitations.
Fitness professionals play a vital role in the delivery of health care to obese individuals. This is specially true given the increasing need for expertise in weight management and weight loss in health care settings. As such, the opportunity, as well as the responsibility, to provide the highest quality of care to obese individuals is great. To maximize effectiveness of efforts, fitness professionals should strive to provide a welcoming, safe environment for all clients, and become versed in the techniques and communication skills that foster positive health experiences for obese individuals. Facilities and staff should be accessible, nondiscriminatory, and unintimidating. Interactions with obese individuals should be conducted without presumption and with special effort toward understanding the client's experience. And although most obese clients will be seeking help in weight management, it is important for fitness professionals to find success in achievement of positive lifestyle changes that do not necessarily result in weight loss. Achievement of behavior change with or without actual weight loss can be celebrated, and the building of self-esteem through small successes is immeasurably important.
Without a focus on bias prevention, one's ability to establish the level of comfort required for long-term client success can be compromised. By providing a supportive environment, cultivating additional skills, and developing an attitude of nonjudgment, openness, and empathy, fitness professionals may increase chances of fruitful interactions with obese clients and enhance success of adopting positive lifestyle changes.
For more information on weight bias, please visit the following Web site: www.yaleruddcenter.org and click on "weight bias."
Weight bias is prevalent among health providers, and fitness professionals have an important role to play in preventing bias toward their overweight and obese clients.
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