The Stigma of Obesity: A Review and Update

Abstract

Obese individuals are highly stigmatized and face multiple forms of prejudice and discrimination because of their weight ((1),(2)). The prevalence of weight discrimination in the United States has increased by 66% over the past decade ((3)), and is comparable to rates of racial discrimination, especially among women ((4)). Weight bias translates into inequities in employment settings, health-care facilities, and educational institutions, often due to widespread negative stereotypes that overweight and obese persons are lazy, unmotivated, lacking in self-discipline, less competent, noncompliant, and sloppy ((2),(5),(6),(7)). These stereotypes are prevalent and are rarely challenged in Western society, leaving overweight and obese persons vulnerable to social injustice, unfair treatment, and impaired quality of life as a result of substantial disadvantages and stigma. In 2001, Puhl and Brownell published the first comprehensive review of several decades of research documenting bias and stigma toward overweight and obese persons ((2)). This review summarized weight stigma in domains of employment, health care, and education, demonstrating the vulnerability of obese persons to many forms of unfair treatment. Despite evidence of weight bias in important areas of living, the authors noted many gaps in research regarding the nature and extent of weight stigma in various settings, the lack of science on emotional and physical health consequences of weight bias, and the paucity of interventions to reduce negative stigma. In recent years, attention to weight bias has increased, with a growing recognition of the pervasiveness of weight bias and stigma, and its potential harmful consequences for obese persons. The aim of this article is to provide an update of scientific evidence on weight bias toward overweight and obese adults through a systematic review of published literature since the 2001 article by Puhl and Brownell. This review expands upon previous findings of weight bias in major domains of living, documents new areas where weight bias has been studied, and highlights ongoing research questions that need to be addressed to advance this field of study. A systematic literature search of studies published between January 2000 and May 2008 was undertaken on computerized psychological, medical, social science, sport, and education databases including PsycINFO, PubMed, SCOPUS, ERIC, and SPORTDiscus. The following keyword combinations were used: weight, obese, obesity, overweight, BMI, fat, fatness, size, heavy, large, appearance, big, heavyweight, bias, biased, discrimination, discriminatory, discriminate, stigma, stigmatized, stigmatization, prejudice, prejudicial, stereotype(s), stereotypical, stereotyping, victimization, victimize(d), blame(d), blaming, shame(d), shaming, teasing, tease(d), unfair, bully, bullying, harassment, assumptions, attributions, education, health, health care, sales, employment, wages, promotion, adoption, jury, customer service, housing, media, television. Reference lists of retrieved articles and books were also reviewed, and manual searches were conducted in the databases and journals for authors who had published in this field. Most studies retrieved for this review were published in the United States. Any articles published internationally are noted with their country of origin. Research on weight stigma in adolescents and children was excluded from this review, as this literature was recently reviewed elsewhere ((8)). Unpublished manuscripts and dissertations were also excluded. In addition, issues pertaining to measurement of weight stigmatization, and demographic variables affecting vulnerability to weight bias such as gender, age, race, and body weight are not addressed in this review. This article instead primarily reviews the evidence of specific areas where weight bias occurs toward adults and its consequences for those affected. This article is organized similarly to the first review published by Puhl and Brownell ((2)), with sections on weight bias in settings of employment, health care, and education. New sections have been added including weight bias in interpersonal relationships and the media, as well as psychological and physical health consequences of weight bias, and the status of stigma-reduction research. As with the 2001 article, this review also provides an update on legal initiatives to combat weight discrimination, and outlines specific questions for future research. In their 2001 review, Puhl and Brownell summarized research documenting weight-based prejudice and discrimination in employment settings ((2)). At that time, emerging evidence demonstrated that overweight and obese workers face stereotypical attitudes from employers and disadvantages in hiring, wages, promotions, and job termination because of their weight. Since then, there has been an increase in survey research, large population-based studies, and experimental work addressing weight discrimination in employment. Findings are summarized below. Self-report studies indicate that perceptions of weight-based employment discrimination remain common among obese persons. In one survey study of overweight and obese women (N = 2,249), 25% of participants reported experiencing job discrimination because of their weight. In addition, 54% reported weight stigma from co-workers or colleagues and 43% reported experiencing weight stigma from their employers or supervisors ((9)). Examples of weight stigma in employment settings included being the target of derogatory humor and pejorative comments from co-workers and supervisors, and differential treatment because of weight such as not being hired, being denied promotions, or fired because of one's weight. Several recent studies have examined weight discrimination in employment settings using data from the National Survey of Midlife Development in the United States, a nationally representative sample of adults ages 25–74 years. One study (N = 2,838) found that overweight respondents were 12 times more likely, obese respondents were 37 times more likely, and severely obese respondents were 100 times more likely than normal-weight respondents to report employment discrimination. In addition, women were 16 times more likely to report weight-related employment discrimination than men ((10)). Another study using the data of National Survey of Midlife Development in the United States (N = 2,290) found that among individuals who reported weight discrimination in employment almost 60% had experienced this mistreatment an average of four times during their lifetime. The specific types of employment discrimination reported included not being hired for a job, not receiving a promotion, and wrongful termination ((4)). Instances of wrongful termination that have been filed in legal cases typically involve an obese employee who was fired because of his/her weight despite positive performance evaluations and/or despite weight being unrelated to job duties. To date, most studies reflect perceptions by employees that weight was the deciding factor for job termination. A third study analyzing data of National Survey of Midlife Development in the United States (N = 3,437) found that 26% of obese persons and 31% of very obese persons reported discrimination in the workplace, which they attributed to their weight and appearance. Furthermore, very obese persons working in professional jobs were more likely than obese nonprofessionals to report employment discrimination ((11)). Several studies analyzing data from the National Longitudinal Survey of Youth suggest that obesity also negatively affects wages. In one study (N = 12,686), a consistent wage penalty for obese employees was demonstrated, even after controlling for socioeconomic and familial variables, and health limitations. For obese men, the wage penalty ranged from 0.7 to 3.4%. For obese women, the wage penalty was greater and ranged from 2.3 to 6.1% ((12)). The authors suggested that discrimination in training opportunities may explain some of the obesity wage penalty, although it should be noted that they did not test for employer-based discrimination. Another study using National Longitudinal Survey of Youth data (N = 25,843) found that for white females, an increase of 64 pounds above average weight was associated with a 9% decrease in wages, which was approximately equivalent to the difference of 1.5 years of education or 3 years of work experience ((13)). A third study analyzed data from the 1988 wave of the National Longitudinal Survey of Youth when respondents were 23–30 years old (N = 6,601). This analysis revealed that both black and white obese women experienced significant wage penalties, even after controlling for socioeconomic status and other related variables. Compared to their normal-weight counterparts, mildly obese and severely obese white women experienced a decrease in wages of 5.8% and 24%, respectively. Similarly, mildly obese and severely obese black women's wages were 3.3% and 14.6% less than normal-weight black women's wages, respectively. Severely obese white men earned 19.6% less and severely obese black men earned 3.5% less than their normal-weight counterparts ((14)). Other cross-sectional research supports these findings. In a study examining adults living in countries belonging to the European Union (N = 17,767 women and 34,679 men), it was observed that a 10% increase in the average BMI reduced the hourly wages of males by 1.9% and females by 3.3%. In Southern European countries, where citizens are reportedly more concerned with weight gain, the effect was much larger ((15)). Other work analyzing data from the 1984 National Lawyer Survey (N = 722) found that overweight male lawyers were paid less than normal-weight male lawyers ((16)). Weight bias may also help explain studies documenting lower rates of employment for obese individuals. For example, Klarenbach and colleagues analyzed data from t

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