Explicit Weight Bias Research Articles

Development and Assessment of a Course to Reduce Weight Bias in Undergraduate Health Promotion Students

Experiencing discrimination based on body size has numerous health consequences and negatively affects motivation for positive health behaviors. Because weight bias is particularly prevalent among health professionals, interventions to reduce weight bias in this group are essential. The purpose of this mixed-methods, 15-week study was to develop and examine the effect of a college course focused on reducing weight bias in health promotion undergraduates. In this study ( N = 64), quantitative change in implicit and explicit weight bias among students enrolled in a course to reduce weight bias was compared with a control group and two other groups of students in the health promotion degree program. Qualitative data were also analyzed through content analysis of pre- and postsemester writing assignments among students in the course focused on weight bias. Statistical analyses revealed a significant reduction in explicit weight bias among students in the course focused on weight bias with no significant changes in explicit weight bias for any other group. There were no significant changes in implicit weight bias for any group. Content analysis of qualitative data was consistent with the quantitative reductions in extrinsic weight bias. Students shared substantially more nuanced understandings of obesity postsemester. Furthermore, the persistence of internal contradictions in students’ analyses illustrates the particular challenge in reducing implicit bias. These results demonstrate that, although intrinsic weight bias may be more difficult to change, a college course focused on reducing weight bias can facilitate significant reductions in extrinsic weight bias among health promotion undergraduates.

“Weak, Sad, and Lazy Fatties”: Adolescents’ Explicit and Implicit Weight Bias Following Exposure to Weight Loss Reality TV Shows

ABSTRACTWeight loss reality TV shows, which portray obese individuals and their struggle to lose weight, are highly popular. However, the shows often contain negative and stereotypical portrayals of obese individuals that can contribute to the formation of weight bias among viewers. In particular, adolescents might be highly susceptible to such portrayals, since physical appearance and body image play an important role during adolescence. In our experimental study, we investigated the priming effects of exposure to weight loss reality TV shows on implicit and explicit attitudes toward obese individuals among 353 adolescents. We exposed a treatment group (n = 173) to video clips of a weight loss reality TV show and a control group (n = 180) to video clips of an information-based TV magazine. Results indicated that for individuals who expressed a fear of being obese, exposure to the weight loss reality TV show reinforced negative explicit attitudes toward obese individuals by activating a perception of weight controllability. Exposure to the weight loss reality TV show also enhanced negative implicit attitudes toward obese individuals among all adolescents, irrespective of their fear of being obese. Altogether, our findings underscore the role of media in perpetuating weight bias.

The Effects of Obesity-Related Health Messages on Explicit and Implicit Weight Bias.

The pervasiveness of explicit and implicit weight bias (WB) defined as negative stereotypes and prejudice regarding one’s weight has been observed among individuals of all weight categories. As a source of WB, health messages have been discussed due to reinforcing stigmatizing notions. The present study sought to investigate whether health messages (i.e., eat healthy, become physically active) have the potential to increase explicit and implicit WB. Participants (N = 144) from the community were randomized to either an experimental group (EG) or a control group (CG). While the EG was presented with health messages, the CG was presented with neutral information. Before and after manipulation, participants completed measures of explicit and implicit WB. Paired samples t-test revealed no differences in explicit WB after manipulation, however, a small effect decrease of implicit WB in the EG but not in the CG was found. This study provided evidence that health messages might have differential impact to change WB. According to dual-model approaches, explicit and implicit WB tap into two different information processing systems, and thus were differentially affected by health messages. Brief exposure to health messages might have the potential to contribute to health behavior and to mitigate implicit WB.

The prevalence and practice impact of weight bias amongst Australian dietitians

SummaryObjectivesThis study explored weight bias amongst Australian Accredited Practising Dietitians (APDs) and the effect of client weight status on dietetic practice.MethodsParticipants were 201 APDs, recruited using purposive sampling. A self‐administered questionnaire, the fat phobia scale (FPS), was completed to assess explicit weight bias. Participants were then randomized to receive either a female within the healthy weight range or female with obesity, accompanied by an identical case study for a condition unrelated to weight. Participants assessed the client based on data provided, provided recommendations and rated their perception of the client.ResultsMean FPS scores indicated mild fat phobia. However, dietetic practice was significantly affected by the client's weight status. Dietitians presented with the female with obesity assessed the client to have significantly lower health and were more likely to provide unsolicited weight management recommendations. In addition, dietitians rated the client as less receptive, less motivated and as having a lower ability to understand and sustain recommendations.ConclusionsThe contribution of this study is the exploration of how weight status may impact dietetic practice including assessment, recommendations and perceptions of the client. Dietitians may practice in a manner that represents or could be perceived as negative implicit weight bias, despite the explicit FPS assessing only mild fat phobia. Further research to understand the extent of the problem and how it impacts client outcomes and to test possible solutions is required.

Empathy and perspective-taking: Examination and comparison of strategies to reduce weight stigma.

Considerable evidence indicates that individuals with obesity are vulnerable to stigma and discrimination. However, comparably less research has examined strategies to reduce weight bias, and the existing evidence is mixed. To help clarify these findings and incorporate prejudice-reduction interventions that have been successfully applied to other stigmatized groups (i.e., empathy-induction and perspective-taking), we experimentally tested and compared four different, brief stigma-reduction interventions in a national sample of American adults. Participants (N = 650) were randomly assigned to 1 of 4 experimental conditions (Empathy, Perspective-Taking, Causal Information, or Empathy/Information Hybrid) or a control condition. Outcome variables included explicit weight bias (Fat Phobia), social distance, and affective reactions to individuals with obesity. The empathy and perspective-taking conditions induced more empathy than the control and informational conditions, and altered affective reactions towards persons with obesity in the expected directions. However, no experimental condition reduced Fat Phobia or social distance relative to the control condition. The current findings suggest that empathy-evoking and perspective-taking strategies may increase empathy and alter affective reactions towards individuals with obesity; however, these strategies remain questionable as effective means to reduce weight stigma.

“You better not leave me shaming!”: Conditional indirect effect analyses of anti-fat attitudes, body shame, and fat talk as a function of self-compassion in college women

The present investigation provided a theoretically-driven analysis testing whether body shame helped account for the predicted positive associations between explicit weight bias in the form of possessing anti-fat attitudes (i.e., dislike, fear of fat, and willpower beliefs) and engaging in fat talk among 309 weight-diverse college women. We also evaluated whether self-compassion served as a protective factor in these relationships. Robust non-parametric bootstrap resampling procedures adjusted for body mass index (BMI) revealed stronger indirect and conditional indirect effects for dislike and fear of fat attitudes and weaker, marginal effects for the models inclusive of willpower beliefs. In general, the indirect effect of anti-fat attitudes on fat talk via body shame declined with increasing levels of self-compassion. Our preliminary findings may point to useful process variables to target in mitigating the impact of endorsing anti-fat prejudice on fat talk in college women and may help clarify who is at higher risk.

Examining Associations of Sexual Attraction and Attitudes on Women's Disordered Eating Behavior.

We aimed to expand the scant research on disordered eating in women identifying same-sex sexual attractions. We used multiple linear regressions to explore potential mechanisms driving disordered eating--both explicit and implicit weight bias and heterosexism--in a cross-sectional, online-recruited community sample of women (N = 437). Participants endorsed a range of sexual attractions from exclusively opposite-sex (21.1%) to exclusively same-sex (19.5%) attraction. Findings revealed no associations between sexual attraction and disordered eating. Awareness of sociocultural norms valuing thinness accounted for disordered eating for all women, regardless of sexual attraction, and was influenced by attitudes regarding weight. Among women endorsing same-sex attractions, self-reported internalized heterosexism influenced disordered eating. Findings contradict long-held beliefs that same-sex attracted women are protected from disordered eating. They emphasize a universal risk, for all women, of sociocultural norms valuing thinness, as well as the risk of internalized heterosexism among same-sex attracted women.

The mixed impact of medical school on medical students' implicit and explicit weight bias.

Health care trainees demonstrate implicit (automatic, unconscious) and explicit (conscious) bias against people from stigmatised and marginalised social groups, which can negatively influence communication and decision making. Medical schools are well positioned to intervene and reduce bias in new physicians. This study was designed to assess medical school factors that influence change in implicit and explicit bias against individuals from one stigmatised group: people with obesity. This was a prospective cohort study of medical students enrolled at 49 US medical schools randomly selected from all US medical schools within the strata of public and private schools and region. Participants were 1795 medical students surveyed at the beginning of their first year and end of their fourth year. Web-based surveys included measures of weight bias, and medical school experiences and climate. Bias change was compared with changes in bias in the general public over the same period. Linear mixed models were used to assess the impact of curriculum, contact with people with obesity, and faculty role modelling on weight bias change. Increased implicit and explicit biases were associated with less positive contact with patients with obesity and more exposure to faculty role modelling of discriminatory behaviour or negative comments about patients with obesity. Increased implicit bias was associated with training in how to deal with difficult patients. On average, implicit weight bias decreased and explicit bias increased during medical school, over a period of time in which implicit weight bias in the general public increased and explicit bias remained stable. Medical schools may reduce students' weight biases by increasing positive contact between students and patients with obesity, eliminating unprofessional role modelling by faculty members and residents, and altering curricula focused on treating difficult patients.

The Obesity Action Coalition: Giving Voice to People Living with Obesity

Obesity is well-documented to be a highly stigmatized disease complicated by a high prevalence of both explicit and implicit weight bias. This bias leads to discrimination in education, healthcare, employment, and social interactions -- often with little recourse or protection for the people affected. Public policies to address obesity have historically placed an implicitly low value on the unmet needs of people with obesity. Resources were instead disproportionately directed into prevention efforts. Until recently, options and resources for clinical care of people with obesity have been limited. Regulatory authorities set unreasonably high bars for innovative treatments that stifled innovation for almost a decade. Blunt assessments from policymakers presented to leaders in obesity medicine and bariatric surgery made it plain that without a strong voice for people living with obesity, these conditions would not change. In response to this situation, the Obesity Action Coalition (OAC) was incorporated in 2005 as a 501(c)(3) nonprofit organization to elevate and empower people affected by obesity though education, advocacy, and support. The OAC has grown to nearly 50000 members, distributed more than 1.5 million pieces of educational materials, confronted weight bias, forged advocacy partnerships, and successfully advocated for more innovation in obesity treatment options. Through its annual meeting, OAC brings together more than 500 people to learn, provide mutual support, and develop advocates. The presentation will review key milestones and factors for a successful advocacy, education, and support organization serving people living with obesity.

A multinational examination of weight bias: predictors of anti-fat attitudes across four countries.

As rates of obesity have increased throughout much of the world, so too have bias and prejudice toward people with higher body weight (that is, weight bias). Despite considerable evidence of weight bias in the United States, little work has examined its extent and antecedents across different nations. The present study conducted a multinational examination of weight bias in four Western countries with comparable prevalence rates of adult overweight and obesity. Using comprehensive self-report measures with 2866 individuals in Canada, the United States, Iceland and Australia, the authors assessed (1) levels of explicit weight bias (using the Fat Phobia Scale and the Universal Measure of Bias) and multiple sociodemographic predictors (for example, sex, age, race/ethnicity and educational attainment) of weight-biased attitudes and (2) the extent to which weight-related variables, including participants' own body weight, personal experiences with weight bias and causal attributions of obesity, play a role in expressions of weight bias in different countries. The extent of weight bias was consistent across countries, and in each nation attributions of behavioral causes of obesity predicted stronger weight bias, as did beliefs that obesity is attributable to lack of willpower and personal responsibility. In addition, across all countries the magnitude of weight bias was stronger among men and among individuals without family or friends who had experienced this form of bias. These findings offer new insights and important implications regarding sociocultural factors that may fuel weight bias across different cultural contexts, and for targets of stigma-reduction efforts in different countries.

Marriage and Family Therapy Trainees' Reports of Explicit Weight Bias.

Discrimination based on an individual's weight has been observed in health care, education, retail, and other public sectors (Puhl & Huer, Obesity, 17, 941, 2007). Such inequity, known as "weight bias," generates negative short-term and long-term consequences for the individuals that experience it (Puhl & Brownell, Weight bias in health care settings, 2007). Past research has shown that healthcare trainees exhibit weight bias (Phelan etal., Obesity, 22, 1201, 2014; Wigton & McGaghie, Journal of General Internal Medicine, 16, 262, 2001), yet little focus is given to weight bias in marriage and family therapy (MFT) education. The purpose of this study was to survey MFT students (N=162) to explore weight bias and how contextual factors associate with weight bias. Participants in MFT programs reported explicit weight bias, with specific contextual factors associating with more bias. Female participants reported more fear of gaining weight, and individuals who identified as overweight had higher rates of explicit weight bias. Contextual differences and implications for training programs are discussed.

Stereotypical portrayals of obesity and the expression of implicit weight bias

The strength of implicit anti-fat attitudes may be related to visual portrayals of obesity and individuals’ pre-existing explicit attitudes toward appearance and weight. Participants (N=117) completed measures of explicit weight bias, beliefs about weight controllability, orientation toward personal appearance, overweight preoccupation, and two Implicit Association Tests (IAT). One IAT measured implicit anti-fat attitudes when individuals with obesity were shown engaging in behaviors congruent with common stereotypes (e.g., eating snacks, watching television), while a second IAT measured attitudes in response to stereotypically incongruent images (e.g., preparing vegetables, exercising). Whereas implicit weight bias was evident for both IATs, the stereotype congruent IAT was significantly related to higher implicit weight bias, appearance orientation, and overweight preoccupation, and was marginally related to explicit anti-fat attitudes. The stereotypical portrayal of individuals with obesity was related to implicit anti-fat attitudes, which may have implications for the development, maintenance, and expression of stigmatizing anti-fat attitudes.

Implicit cognitive processes in binge-eating disorder and obesity

ObjectivesBinge-eating disorder (BED) is characterized by recurrent binge eating episodes, associated eating disorder and general psychopathology, and commonly occurs in obese individuals. Explicit self-esteem and explicit weight bias have been linked to BED, while little is known about implicit cognitive processes such as implicit self-esteem and implicit weight bias. MethodsObese participants with BED and an individually matched obese only group (OB) and normal weight control group (CG; each N = 26) were recruited from the community to examine group differences and associations in explicit and implicit self-esteem and weight bias, as well as the impact of implicit cognitive processes on global eating disorder psychopathology. Implicit cognitive processes were assessed using the Implicit Association Test. ResultsSignificantly lower explicit self-esteem, as well as higher exposure to explicit weight bias, compared to CG and OB was found in the BED group. All groups showed positive implicit self-esteem, however, it was significantly lower in BED when compared to CG. BED and CG demonstrated equally high implicit weight bias whereas OB did not. Explicit and implicit measures were not significantly correlated. Global eating disorder psychopathology was predicted by explicit and implicit self-esteem. ConclusionsThe results of the present study add to the importance of implicit self-esteem and implicit weight bias beyond explicit measures in BED, while both were previously shown to be associated with onset and maintenance of BED. In conclusion, implicit cognitive processes should be focused on in interventions for BED to investigate their impact on psychological treatments.

Implicit and explicit weight bias in a national sample of 4,732 medical students: The medical student CHANGES study

ObjectiveTo examine the magnitude of explicit and implicit weight biases compared to biases against other groups; and identify student factors predicting bias in a large national sample of medical students.Design and MethodsA web-based survey was completed by 4732 1st year medical students from 49 medical schools as part of a longitudinal study of medical education. The survey included a validated measure of implicit weight bias, the implicit association test, and 2 measures of explicit bias: a feeling thermometer and the anti-fat attitudes test.ResultsA majority of students exhibited implicit (74%) and explicit (67%) weight bias. Implicit weight bias scores were comparable to reported bias against racial minorities. Explicit attitudes were more negative toward obese people than toward racial minorities, gays, lesbians, and poor people. In multivariate regression models, implicit and explicit weight bias was predicted by lower BMI, male sex, and non-Black race. Either implicit or explicit bias was also predicted by age, SES, country of birth, and specialty choice.ConclusionsImplicit and explicit weight bias is common among 1st year medical students, and varies across student factors. Future research should assess implications of biases and test interventions to reduce their impact.

Overweight People Have Low Levels of Implicit Weight Bias, but Overweight Nations Have High Levels of Implicit Weight Bias

Although a greater degree of personal obesity is associated with weaker negativity toward overweight people on both explicit (i.e., self-report) and implicit (i.e., indirect behavioral) measures, overweight people still prefer thin people on average. We investigated whether the national and cultural context – particularly the national prevalence of obesity – predicts attitudes toward overweight people independent of personal identity and weight status. Data were collected from a total sample of 338,121 citizens from 71 nations in 22 different languages on the Project Implicit website (https://implicit.harvard.edu/) between May 2006 and October 2010. We investigated the relationship of the explicit and implicit weight bias with the obesity both at the individual (i.e., across individuals) and national (i.e., across nations) level. Explicit weight bias was assessed with self-reported preference between overweight and thin people; implicit weight bias was measured with the Implicit Association Test (IAT). The national estimates of explicit and implicit weight bias were obtained by averaging the individual scores for each nation. Obesity at the individual level was defined as Body Mass Index (BMI) scores, whereas obesity at the national level was defined as three national weight indicators (national BMI, national percentage of overweight and underweight people) obtained from publicly available databases. Across individuals, greater degree of obesity was associated with weaker implicit negativity toward overweight people compared to thin people. Across nations, in contrast, a greater degree of national obesity was associated with stronger implicit negativity toward overweight people compared to thin people. This result indicates a different relationship between obesity and implicit weight bias at the individual and national levels.

Weight bias among professionals treating eating disorders: Attitudes about treatment and perceived patient outcomes

This study aimed to assess weight bias among professionals who specialize in treating eating disorders and identify to what extent their weight biases are associated with attitudes about treating obese patients. Participants were 329 professionals treating eating disorders, recruited through professional organizations that specialize in eating disorders. Participants completed anonymous, online self-report questionnaires, assessing their explicit weight bias, perceived causes of obesity, attitudes toward treating obese patients, perceptions of treatment compliance and success of obese patients, and perceptions of weight bias among other practitioners. Negative weight stereotypes were present among some professionals treating eating disorders. Although professionals felt confident (289; 88%) and prepared (276; 84%) to provide treatment to obese patients, the majority (184; 56%) had observed other professionals in their field making negative comments about obese patients, 42% (138) believed that practitioners who treat eating disorders often have negative stereotypes about obese patients, 35% (115) indicated that practitioners feel uncomfortable caring for obese patients, and 29% (95) reported that their colleagues have negative attitudes toward obese patients. Compared to professionals with less weight bias, professionals with stronger weight bias were more likely to attribute obesity to behavioral causes, expressed more negative attitudes and frustrations about treating obese patients, and perceived poorer treatment outcomes for these patients. Similar to other health disciplines, professionals treating eating disorders are not immune to weight bias. This has important implications for provision of clinical treatment with obese individuals and efforts to reduce weight bias in the eating disorders field.

The effect of physicians’ body weight on patient attitudes: implications for physician selection, trust and adherence to medical advice

Research has documented negative stigma by health providers toward overweight and obese patients, but it is unknown whether physicians themselves are vulnerable to weight bias from patients. This study assessed public perceptions of normal weight, overweight or obese physicians to identify how physicians' body weight affects patients' selection, trust and willingness to follow the medical advice of providers. An online sample of 358 adults were randomly assigned to one of three survey conditions in which they completed a questionnaire assessing their perceptions of physicians who were described as normal weight, overweight or obese. Participants also completed a measure of explicit weight bias (Fat Phobia Scale) to determine whether antifat attitudes are associated with weight-related perceptions of physicians. Respondents reported more mistrust of physicians who are overweight or obese, were less inclined to follow their medical advice, and were more likely to change providers if the physician was perceived to be overweight or obese, compared to normal-weight physicians who elicited significantly more favorable reactions. These weight biases remained present regardless of participants' own body weight. Inspection of interaction effects revealed opposing effects of weight bias between the obese/overweight and normal-weight physician conditions. Stronger weight bias led to higher trust, more compassion, more inclination to follow advice, and less inclination to change doctors when the physician was presented as normal weight. In contrast, stronger weight bias led to less trust, less compassion, less inclination to follow advice and higher inclination to change doctors when the physician was presented as obese. This study suggests that providers perceived to be overweight or obese may be vulnerable to biased attitudes from patients, and that providers' excess weight may negatively affect patients' perceptions of their credibility, level of trust and inclination to follow medical advice.

The Impact of Professional Development About Weight-Related Issues for Pre-Service Teachers: A Pilot Study

Many teachers do not have a working knowledge of body image or weight issues. This pilot project examined body image satisfaction and eating/weight-related behaviours before and after a professional in-service with physical education pre-service teachers (N = 16). At the three- month follow-up, measures were repeated and qualitative data (critical incidents and a focus group) about the impact on teaching practice was collected. Results showed no significant changes, however pre-service teachers indicated (a) attempting to lose weight or gain muscle (despite many being in a healthy weight range), and (b) having a biased approach to weight-related issues. Pre-service teachers, particularly those specializing in physical education, are not immune to cultural messages that perpetuate the thin ideal. Future evaluation with a larger sample that formally measures implicit and explicit weight-bias is needed. Providing professional development for pre-service teachers may promote more positive practice about body image, weight-bias, and weight/eating-related concerns in schools.

The harmful and beneficial impacts of weight bias on well-being: The moderating influence of weight status

Weight bias is evident among normal weight and obese individuals. This weight bias may be associated with comparisons to others, which may enhance feelings of self-worth. However, the ego-enhancing versus ego-diminishing influence of these evaluations may be moderated by the individual's weight status, and the strength of these effects may be moderated by gender. Eight-five participants completed the Implicit Associations Test, questionnaires assessing explicit weight bias, body image, and self-esteem, and height and weight assessments. Implicit weight bias was prevalent among all individuals, p < .001, and was associated with a more positive body image, ps < .05, and higher self-esteem, ps < .01, for thinner individuals but a more negative body image and lower self-esteem for heavier individuals. Gender moderation effects were not observed. It is arguably problematic that the positive benefits to normal weight individuals’ self-esteem and body image appear to come via negative comparisons with overweight individuals.

Implicit, explicit, and internalized weight bias and psychosocial maladjustment among treatment-seeking adults

Objective Weight bias among weight loss treatment-seeking adults has been understudied. This investigation examined the 1) levels of implicit, explicit, and internalized weight bias among overweight/obese treatment-seeking adults, 2) association between weight bias and psychosocial maladjustment (binge eating, body image, depression), and 3) association between participation in weight loss treatment and changes in weight bias. Methods Fifty-four overweight and obese individuals (BMI ≥ 27) recruited for a weight loss intervention completed measures of depression, body image, binge eating, and implicit, explicit, and internalized weight bias. Results Participants evidenced significant implicit, explicit, and internalized weight bias. Greater weight bias was associated with greater depression, poorer body image, and increased binge eating. Despite significant reductions in negative internalized and explicit weight bias following treatment, weight bias remained strong. Conclusions Weight bias among treatment-seeking adults is associated with greater psychological maladjustment and may interfere with their ability to achieve optimal health and well-being.