ArticlePDF Available
EDITORIAL
published: 11 December 2017
doi: 10.3389/fpsyg.2017.02149
Frontiers in Psychology | www.frontiersin.org 1December 2017 | Volume 8 | Article 2149
Edited by:
Alix Timko,
University of Pennsylvania,
United States
Reviewed by:
Paula M. Brochu,
Nova Southeastern University,
United States
*Correspondence:
Stuart W. Flint
s.w.flint@leedsbeckett.ac.uk
Specialty section:
This article was submitted to
Eating Behavior,
a section of the journal
Frontiers in Psychology
Received: 22 September 2017
Accepted: 27 November 2017
Published: 11 December 2017
Citation:
Flint SW, Oliver EJ and Copeland RJ
(2017) Editorial: Obesity Stigma in
Healthcare: Impacts on Policy,
Practice, and Patients.
Front. Psychol. 8:2149.
doi: 10.3389/fpsyg.2017.02149
Editorial: Obesity Stigma in
Healthcare: Impacts on Policy,
Practice, and Patients
Stuart W. Flint 1
*, Emily J. Oliver 2and Robert J. Copeland 3
1Carnegie School of Sport, Leeds Beckett University, Leeds, United Kingdom, 2Department of Sport and Exercise Sciences,
Durham University, Durham, United Kingdom, 3Centre of Sport and Exercise Science, Sheffield Hallam University, Sheffield,
United Kingdom
Keywords: weight stigma, healthcare, higher weight, anti-fat attitudes, weight bias
Editorial on the Research Topic
Obesity Stigma in Healthcare: Impacts on Policy, Practice, and Patients
INTRODUCTION AND EDITION PURPOSE
Obesity prevalence is a global health concern. Alongside increasing awareness of the condition
are concomiteted increases in reported weight stigma and discrimination toward people with
obesity. Counter-intuitively, research has identified weight stigma in settings that are critical for
the engagement and treatment of people with obesity, such as exercise (Robertson and Vohora,
2008; Flint and Reale, 2016), healthcare facilities (Brown and Flint, 2013), schools (Puhl and
Luedicke, 2012), and workplaces (Roehling, 1999; Flint et al., 2016). The prevalence and robustness
to interventions to reduce anti-fat attitudes is concerning (Flint et al., 2013) given their association
with anti-fat behavior (O’Brien et al., 2008). For instance, healthcare professionals and students in
training report stigmatizing attitudes and beliefs toward higher-weight people, and in some cases,
withhold appropriate advice or treatment (e.g., Kristeller and Hoerr, 1997; Hebl and Xu, 2001).
In addition, healthcare providers use stigmatizing terminology in consultations and other patient-
practitioner meetings, with adverse effects (e.g., avoidance of healthcare settings, and compromised
psychosocial wellbeing: depressed mood, anxiety, social isolation, and lower self-esteem) (e.g.,
Vartanian and Novak, 2011).
Despite accumulating evidence demonstrating prevalent weight stigma in healthcare settings,
current knowledge of the impact of weight stigma within healthcare remains underdeveloped.
In a dynamic context whereby the legal and social standing of higher weight people is the
subject of contemporary debate, an evidence-based review of understanding and practice is
timely. Existing research has provided useful and critical insight into the prevalence, breadth
and nature of anti-fat biases and weight stigma within healthcare professionals and settings.
Increasingly, we are aware of how these biases might influence treatment and the patient
experience. Conceptualizing existing research as predominantly addressing these first generation’
questions, in editing the current Research Topic, we sought to present emerging work that explores
second and third generation questions. These concern, for example, differential predictors of
patients’ reactivity to weight stigma, new interventions for modification of weight self-stigma, and
theoretically-grounded critical reflections on how stigma is experienced and socially constructed.
Flint et al. Obesity Stigma in Healthcare
We include work from all stages of the healthcare pathway,
exploring: whether and how theory and evidence concerning
weight stigma are reflected in policy and guidance, how stigma
is influencing professionals and their practice, and how patients
are affected.
SUMMARY OF CONTRIBUTING ARTICLES
This Research Topic opens with Lee and Pause’s auto-
ethnographic account of fat stigma and discrimination that
people experience from the medical profession and other sectors
of the community. Novel contributions are made through the
authors’ consideration of Bacon and Aphramor’s “Health and
Every Size” paradigm as a path to health for individuals who
are fat, raising critical questions concerning the nature of health
as a state, behavior, commodity, or social contract. Importantly,
this article presents research into the barriers to accessing and
adoption of health behaviors from the perspective of higher
weight researchers. In doing so, the authors consider whether
the “Health at every Size” paradigm is an appropriate health
perspective that higher weight people can utilize. Drawing from
feminist theory, the authors challenge a perceived failure to
provide evidenced-based healthcare to higher weight people.
The second paper (Rudolph and Hilbert) presents an
experimental examination of the impact of obesity-related health
messages on implicit and explicit weight bias. Rudolph and
Hilbert’s study examined the use of health messages promoting
healthy eating and physical activity on subsequent implicit and
explicit weight bias comparing the findings against a control arm
that contained neutral information. The authors reported a small
difference in reduced implicit weight bias in the experimental
condition (health messages) but not in the control condition
(neutral messages). Despite this positive finding, there was no
difference in explicit weight bias. Given the commonality of
health messages, further research that examines the implications
on weight bias appears warranted.
The third paper (Meadows et al.) explored the effects of both
the amount of contact with higher weight people before and
during medical school and of training to induce empathy toward
patients on anti-fat attitudes. An online survey was completed
by students in their first year and again in their fourth year of
medical school. After 4 years of medical school, greater contact
with higher weight patients improved attitudes toward higher
weight patients, however, this effect was not as strong for attitudes
toward higher weight people. Differing effects were reported
for the impact of training to include empathy toward patients,
where greater effect was observed for participants who were more
egalitarian and empathetic at baseline. This study along with
other interventions (e.g., Flint et al., 2013) that have shown only
a small effect in reducing weight stigma, reinforce the need for
interventions to improve attitudes toward higher weight people.
The fourth study (Raves et al.) used a mixed-methods
design (survey responses, ethnographic data and multi-year
participant-observations within a clinical setting) to examine
the relationship between weight stigma and post-surgical dietary
response; whether weight loss reduces weight stigma; and patient
and provider perspectives on stigma and healthcare adherence.
Raves et al. reported that weight stigma internalization and
experiences of weight stigma predicted worse dietary adherence;
patients were ambivalent of the stigma to adherence relationship,
whereas healthcare professionals viewed this as poor patient
compliance. This study provides evidence of weight stigma in
healthcare, and that internalization and experiences of weight
stigma reduces healthcare adherence, highlighting the need for
intervention to improve adherence and potentially outcomes.
The final two articles discuss the use of terminologies and
labels used in policy, research, healthcare and other contexts.
First, Lozano-Sufrategui et al. discuss the terminology used
by the National Institute for Health and Care Excellence in
England within the national guidance for improving health
and social care in England given the status of NICE in
shaping the discourse relating to obesity. Second, Meadows
and Daníelsdóttir suggest that more neutral terms such
as “weight” and “higher weight” be used as more neutral
and acceptable terms that carry less culturally constructed
values.
EMERGENT RECOMMENDATIONS
Collectively, the work in this special issue underpins a
number of recommendations. First, we recommend that
clinicians, researchers, health practitioners, exercise specialists
and policy makers carefully avoid labeling higher weight
patients with culturally stigmatizing terminology. While there
may be diagnostic settings where more specific terminology
is required, we support calls in this Research Topic for
healthcare professionals to understand what terms are acceptable
for their patients. For instance, in some cases the use of
“higher weight” or “fat” might be acceptable for patients. It
is therefore imperative that healthcare professionals establish
the most acceptable terms to use with their patients to
avoid potential disengagement and associated implications
for the patient-practitioner relationship. Second, we call for
researchers to develop effective and innovative interventions to
sustainably reduce weight stigmatizing attitudes and practices.
Work thus far is dominated by acute experimental studies;
more translational research into practice-focused interventions
is required. Third, and finally, that research and policy makers
consider resources for engaging and supporting higher weight
people and mandatory training of practitioners through a stigma-
awareness raising lens, given the potential impact of these on the
patient healthcare outcomes.
AUTHOR CONTRIBUTIONS
SF, EO, and RC drafted, revised and finalized the content of
the manuscript. All authors have read and approved the final
manuscript.
Frontiers in Psychology | www.frontiersin.org 2December 2017 | Volume 8 | Article 2149
Flint et al. Obesity Stigma in Healthcare
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Conflict of Interest Statement: The authors declare that the research was
conducted in the absence of any commercial or financial relationships that could
be construed as a potential conflict of interest.
Copyright © 2017 Flint, Oliver and Copeland. This is an open-access article
distributed under the terms of the Creative Commons Attribution License (CC BY).
The use, distribution or reproduction in other forums is permitted, provided the
original author(s) or licensor are credited and that the original publication in this
journal is cited, in accordance with accepted academic practice. No use, distribution
or reproduction is permitted which does not comply with these terms.
Frontiers in Psychology | www.frontiersin.org 3December 2017 | Volume 8 | Article 2149
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The aim of this study was to investigate discrimination against obese job candidates, and to examine whether widely used measures of implicit and explicit antifat attitudes are related to or predict antifat discrimination. One hundred university students made job candidate suitability ratings of resumes submitted for a bogus managerial position. Photos attached to each resume portrayed the job candidate as either obese or normal weight, by using pre- and postprocedure photos of individuals who had undergone bariatric surgery. To assess discrimination, job candidates' ratings were compared between obese and normal-weight targets. Implicit and explicit antifat attitudes were also assessed. Participants rated obese job candidates as having less leadership potential, as less likely to succeed, and as less likely to be employed than normal-weight candidates. Obese candidates were also given a lower starting salary and ranked as less qualified overall than candidates portrayed as normal weight. Neither implicit nor explicit antifat attitude measures were significantly related to antifat discrimination. This study found strong evidence of employment-related discrimination against obese individuals. Commonly used measures of antifat attitudes do not appear to be adequate predictors of antifat discrimination. Improved questionnaire measures may be needed to better predict actual prejudiced behavior.
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The aim of this study was to qualitatively examine weight stigma in individuals who exercise frequently. In total, six focus groups, comprising 30 participants aged 18–25 years, were conducted using convenience sampling. All participants were frequent exercisers. Five themes emerged in the data with participants discussing bullying, the consequences of obesity, causes of obesity, lack of willpower and interventions to reduce obesity. This study is the first qualitative examination of weight stigmatisation in frequent exercisers, where the beliefs reported by focus group participants suggest that frequent exercisers stigmatise, discriminate and dehumanise obese people. Future research to examine the impact of weight stigma on exercise motivation and behaviour of obese people appears warranted.
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This article takes an interdisciplinary approach to the issue of weight-based discrimination in employment, drawing on diverse literatures (psychology, law, sociology, economics), and integrating a review of empirical research and a traditional legal analysis. First, empirical research that focuses on the extent of bias against overweight individuals in employment contexts is reviewed and evaluated. Second, current legal requirements relevant to weight-based discrimination in employment are identified and discussed, and those requirements are applied to the research findings to assess the extent to which the weight-based bias identified in the reviewed studies involves illegal discrimination. Third, based on the results of the review of the research and legal literatures, future research directions are offered and practical implications for employers and policy makers are identified.
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Experiences with weight stigma negatively impact both psychological outcomes (e.g., body dissatisfaction, depression) and behavioral outcomes (e.g., dieting, exercise). However, not everyone is equally affected by experiences with weight stigma. This study examined whether internalized societal attitudes about weight moderated the impact of weight stigma. Adult participants (n = 111) completed measures of experiences with weight stigma, as well as two indexes of internalized societal attitudes (the moderators): Internalized anti-fat attitudes and internalization of societal standards of attractiveness. Psychological outcomes included self-esteem, body dissatisfaction, drive for thinness, and bulimic symptoms; behavioral outcomes included avoidance of exercise and self-reported exercise behavior. Weight stigma was positively correlated with body dissatisfaction, drive for thinness, and bulimic symptoms, and was negatively correlated with state and trait self-esteem. Both indexes of internalized attitudes moderated the association between weight stigma and avoidance of exercise: Individuals high in anti-fat attitudes and high in internalization of societal standards of attractiveness were more motivated to avoid exercise if they also experienced a high degree of weight stigma; individuals low in anti-fat attitudes and low in internalization were relatively unaffected. Avoidance of exercise was negatively correlated with self-reported strenuous exercise. These findings suggest that weight stigma can negatively influence motivation to exercise, particularly among individuals who have internalized societal attitudes about weight. Reducing internalization might be a means of minimizing the negative impact of weight stigma and of facilitating healthy weight management efforts.