Anti Fat Bias in Healthcare

Running head: ANTI-FAT BIAS IN HEALTHCARE 1

Anti-Fat Bias: Media’s Influence on Obesity Stigma

and its Impact on Healthcare for Women with Lipoedema

Catherine Seo

Fielding Graduate University

ANTI-FAT BIAS IN HEALTHCARE 2

Abstract

Media’s influence is far reaching. Nowhere does it have more impact than on the

internalized and externalized images the culture projects about women’s bodies. Perfect idealized

images of women, impossible to attain and maintain, are disempowering and lead to widespread

stigma and discrimination. Lipoedema, an inherited genetic Fat Disorder, affects 11% of women

of all sizes, from extremely thin to the morbidly obese, resulting in localized fat that is bilateral,

symmetrical and usually from the waist to just above the ankles. Unlike “normal” fat of obesity,

lipoedemic fat cannot be lost through diet and exercise.

Anti-fat bias is common and along with a lack of knowledge about lipoedema among

healthcare professionals generally results in misdiagnosis for women with the disorder. Despite

its medical vs. cosmetic nature, lipoedema is often confused with obesity and women are judged,

shamed and blamed by healthcare professionals, either implicitly or explicitly. Women learn a

sense of powerlessness in the face of anti-fat bias, and fail to advocate for themselves in

healthcare situations. Cognitive understanding about lipoedema and mindfulness meditation are

two interventions that can increase self-efficacy and self-caring, especially for women with

lipoedema, allowing them to advocate for themselves in receiving appropriate quality healthcare.

Keywords:

Obesity, body image, anti-fat bias, healthcare, stigma, lipoedema, fat disorders, learned

helplessness, self-efficacy, self-caring, mindfulness meditation


Table of Contents

Abstract .......................................................................................................................................... 2 Anti-Fat Bias: Media’s Influence on Obesity Stigma and its Impact on Healthcare for Women with Lipoedema ............................................................................................................... 4 Stigma ............................................................................................................................................. 5

Obesity Stigma ............................................................................................................................ 5 Obesity: An Escalating Crisis ...................................................................................................... 6

Body Mass Index (BMI) ............................................................................................................. 6 Media’s Influence in Obesity Stigma .......................................................................................... 7

Media Effects: Consequences of Obesity Bias ........................................................................... 8 Social Implications of Media Images ......................................................................................... 9 Social Stigma of Obesity .......................................................................................................... 10

Controllability ....................................................................................................................... 10 Anti-fat Bias in Healthcare ........................................................................................................ 12

Explicit and Implicit Anti-fat Bias in Healthcare ..................................................................... 12 Lipoedema: Genetic Inherited Fat Disorder ............................................................................. 14 Impact of Anti-fat Bias on Women’s Health ............................................................................ 14

Survey Responses .................................................................................................................. 14 Anti-Fat Bias: Awareness, Resiliency and Tools for Healing ................................................. 15

Healthcare Awareness: Educating Healthcare Professionals .................................................... 16 Social Awareness: Social Support ............................................................................................ 17 Personal Awareness: Mindfulness, Compassion & Advocacy ................................................. 18

Conclusion: Words of Wisdom from Oprah Winfrey ............................................................. 19 References ..................................................................................................................................... 21


Anti-Fat Bias: Media’s Influence on Obesity Stigma

and its Impact on Healthcare for Women with Lipoedema

Perfect idealized images of women barrage us through the media. Slender, tall, flawless

creatures of desire that appear with a sense of glamor are used again and again to objectify

someone else’s image of women and sexuality. These images certainly don’t represent a true

image of reality. When most women look into the mirror, that’s not at all what they see or

experience, or in truth, want to look like. This media proliferation influences and perhaps

contributes to the cause of many complex issues for girls and women including disordered

eating, body distortions, body and identity shame and numerous radical behaviors in an attempt

to fit into this idealized unrealistic expectation. Paramount to this visual assault is the stigma and

anti-fat bias that has become an integral part of our cultural meme.

Those struggling with body size and body image are internally affected as well as

stigmatized by many of those interacting with them, including and most especially their

healthcare providers. Anti-fat bias affects the general population and has significant impact on

patients by their healthcare providers who explicitly or implicitly carry that prejudice into their

interactions with those who are overweight or obese. The consequence for women with a genetic

hereditary fat disorder, lipoedema, can be particularly critical since misdiagnosis and lack of

treatment exacerbates the condition and as the disorder progresses can lead to dire complications

and for some immobility.

This paper first explores the definition and the causes of stigma and reviews the specifics

of the rising obesity crisis. Then it goes on to examine media’s contribution briefly reviewing the

impact of media images, and media’s influence in creating the narrative and contributing to a

culture of anti-fat bias, most especially in healthcare. In addition, the prevalence of anti-fat bias,


both explicit and implicit, and its impact on women’s health is explored. Current research is

reviewed on cognitive awareness in understanding the role of stigma, especially in relationship to

obesity and fat disorders. Raising awareness in the healthcare system, social support and

mindfulness meditation are reviewed as coping strategies and elements of change in dealing with

weight stigma.

Stigma

Stigma is defined as an extreme form of disapproval or rejection, “deeply discrediting,”

in essence, disgrace that separates someone from the norm. Social stigma, as defined by

Goffman, includes the concept of an aberration of “social identity.” For instance, there exists a

normative expectation that most people adhere to, but those outside that norm, “possess an

attribute that makes them different from others,” are considered deviants who are “reduced in our

minds from a whole and usual person to a tainted, discounted one” (1963, p. 2-3). There exists a

fundamental belief that the stigmatized person is “not quite human” (Goffman, 1963, p. 5).

Referring to Goffman’s seminal work, Kurzban and Leary further detail stigma as a

“process of global devaluation of an individual who possesses a deviant attribute. Stigma

arises during a social interaction when an individual's actual social identity (the attributes

he or she can be proved to possess) does not meet society's normative expectations of the

attributes the individual should possess (his or her virtual social identity). Thus, the

individual's social identity is spoiled, and he or she is assumed to be incapable of

fulfilling the role requirements of social interaction” (2001, p. 187).

Obesity Stigma

Though prejudice and judgment continue to exist within many cultural conditions such as

race, gender orientation and class, there has been progress in identifying and abating the intensity


of the stigma and prejudice within these categories. However, overweight and obesity, especially

in light of the rising epidemic, which has reached crisis proportions, still, remains the “deviant

attribute” to which a lack of compassion gets applied. In fact, it's probably the last stigma where

open ridicule and harassment are often supported.

As Puhl and Heuer from the Yale University Rudd Center for Food Policy & Obesity

reported, “Obese individuals are highly stigmatized and face multiple forms of prejudice and

discrimination because of their weight. The prevalence of weight discrimination in the United

States has increased by 66% over the past decade” (2009, p. 941).

Obesity: An Escalating Crisis

Overweight and obesity continue to escalate despite the rising diet industry and numerous

interventions offered to and attempted by those struggling with obesity. The Centers for Disease

Control (CDC) reported in the National Health and Nutrition Examination Survey (NHANES)

Data Brief that more that 70 % of adults and 33 % of youth in the U.S. are either overweight or

obese (2012). These numbers continue to rise. The Department of Health in the U.K. reported in

it’s Public Policy, classifying 61.3 % of adults and 30 % of children aged between 2 and 15 as

either overweight or obese in England (Soubry, 2013). Predictions continue to show an increase

in the U.K. and as Western eating habits become more widespread globally as well.

Body Mass Index (BMI)

Body Mass Index (BMI) measures body height and weight and is the measurement for

body size. Currently, underweight is defined as Body Mass Index (BMI) < 18.5, normal weight

is defined as (BMI) > 18.5, overweight is defined as (BMI) > 25, and obesity is defined as BMI

> 30. As the trends in obesity have continued to increase globally, additional obesity categories

have been needed to accommodate the rising incidence of morbid obesity and several have been


added including severe obesity (Class II, BMI > 35), morbid obesity (Class III, BMI > 40), and

super obese (BMI > 50) (Strum, 2007).

Though issues of body size and obesity affect both genders, women are by far more

impacted, judged and shamed, and the focus of this paper is on those issues. Media’s influence is

paramount in sculpting the story of thin/fat, and what and how a women’s body should look like,

across cultures. Obesity is referred to in the media as a “crisis.” The graphic below from the

Centers for Disease Control (CDC) illustrates the degree of impact and increase of obesity in the

past 20 years.

Figure 1: Obesity Trends Among U.S. Adults Between 1985 and 2010, CDC

Media’s Influence in Obesity Stigma

Media proliferates distortion and misrepresentation of women’s bodies that have become

a cornerstone to our cultural story. Idealized images are based, in part, on extremes of thinness

and extremes of obesity significantly based on the cultural values we have adopted through


consuming media. Media portrays thinness as the cultural ideal of femininity, while obesity is

affected directly from the onslaught of food advertising.

In When Fantasy Becomes Reality, Dill-Shackleford states, “we are making our girls and

women sick by tolerating the pervasive misrepresentation of femininity in the mass media”

(Kindle edition, 2009, 3332). Women are affected on a daily basis by the stigma attached to body

size and the explicit and implicit responses from others as well as by their own self-judgment,

self-shame and self-blame.

Media Effects: Consequences of Obesity Bias

The common cultural meme or narration tells a story of obese people, with attributes such

as “out-of-control and lazy” (Puhl & Brownell, 2001, p. 792). It is not yet politically incorrect to

vilify those who are obese, and along with that come significant consequences to the individual

and to the social environment within which it exists.

While Western culture has idealized thin women’s bodies, this has not been true in many

other cultures around the world up until more recently. Many Latin and tribal based countries

have esteemed fuller and curvaceous bodies as a symbol of generosity, success, wealth, fertility

and beauty. The Western way of looking at obesity and the onslaught of media reinforcing these

values seem to be over-riding these traditional beliefs resulting in ever-increasing levels of anti-

fat bias, stigma and discrimination globally.

Most cultures of the world for most of history have viewed fatness as a welcome sign of

health and prosperity (Brown & Konner, 1987). A recent study by Brewis, Wutich, Falletta-

Cowden & Rodriguez-Soto (2011) suggested that there is a rapidly growing trend for

globalization of fat stigma. Overweight and obese people in societies previously unbiased

towards fat are being viewed as rejects, ugly, lazy, undesirable and lacking in self-control.


While this story of fat has consequences for those struggling with obesity in many areas

such as employment and education, the most negatively impactful and potentially harmful is in

interactions with healthcare professionals. Anti-fat bias runs rampant with otherwise intelligent

and service-oriented healthcare providers. “By attacking the victims of epidemic obesity, we single

it out from other threats to health for no justifiable reason, compound its harms, and divert resources

from attacking its causes” (Katz, 2011).

Social Implications of Media Images

Media has played a prominent role in creating and growing the visual story about

women’s bodies. Girls and women have learned that their body size, idealized by unrealistic

thinness, is socially more important than mostly any other attribute and have developed shame in

their perceptions of self-identity. Ahern, Bennett, Kelly & Hetherington (2011) reported that

girls and young women, ages 16 – 25 in their study, overtly expressed the negative influence of

social pressures. In reporting about their experience, girls openly revealed that viewing idealized

images in magazines and other media actually worsened their body dissatisfaction and often

prompted those even normal sized to begin to diet in order to lose weight striving for this

unrealistic ideal.

Contributing to the complex issues surrounding overweight and obesity, Herbozo,

Tantleff-Dunn, Gokee-Larose, and Kevin Thompson (2004) reported detailed studies that have

shown children overpoweringly associate traits considered negative with obese images of girls

and women while attributing positive traits with thin and average-sized images of girls and

women. Since there is such a high rate of media consumption, it is not unusual or surprising that

children, as young as preadolescent, express and act on body image concerns. A desire for

thinness and an aversion to obesity is widespread even in very young children. The narrative

goes deep and is instilled early.


“Since young children are frequently exposed to sociocultural ideal body shapes, it is

likely that they have internalized these ideals as well as the prejudice against obesity. In

fact…45% of a sample of girls and boys in grades three through six had a desire to be thinner,

37% had tried to lose weight, and 6.9% scored within the anorexia nervosa range” (Herbozo, et

al., 2004, p. 23).

Social Stigma of Obesity

In mainstream U.S. culture, “obesity is socially stigmatized even to the point of

abhorrence” (Brown & Konner, 1987, p. 39). Advertising and products for weight loss

proliferate in the media, and is a major industry in the U.S. with current analyses of the diet

industry putting the annual total at $58 billion spent on weight-loss products and services. This is

representative of how offensive obesity is perceived to be by the culture, and the level of

activities and diet that many engage in to change it.

Physical attractiveness stereotypes valued by adults are learned early and are also

prevalent in children (Dion, Berscheid, & Walster, 1972). Children ages 6-9 years old associated

positive traits with thin or normal sized body images but associated negative words such as

“fights,” “cheats,” “gets teased,” “lazy,” “lies,” “mean,” “dirty,” and “stupid” with overweight or

obese body images. Tiggemann and Wilson-Barrett (1998) reported stereotyping from both boys

and girls, regardless of age, judging the obese body images as being lazier, less happy, less

popular, and less attractive than the average-size figure.

Controllability

Contrary to theories of “controllability,” diet and exercise are not the primary factors

underlying the complex problem of obesity. Controllability offers the notion that one can

determine or have control over what a system does, how it behaves and ultimately the outcome.


“…attributions of controllability stem from underlying beliefs about causality in the physical and

social world and are intricately related to social ideologies” (Crandall, D'Anello, Sakalli,

Lazarus, Nejtardt, & Feather, 2001, p. 31). Simply put, obesity is blamed on internal,

controllable causes.

It’s important to note that scientific evidence does not support the theory that overeating

and lack of exercise are the primary cause of overweight and obesity. Rather “the majority of

research evidence supports the notion that body weight is the result of genetic and metabolic

factors and is only modestly related to dietary habits” (Crandall, 1994).

Numerous studies support evidence that many physiological factors contribute to

“making dieting both difficult and ineffective…the belief that fat people got that way primarily

from overeating and a lack of self-control does not properly represent the scientific data”

(Crandall, 1994, p. 884).

In essence, many people believe that people get what they deserve and that those who are

overweight or obese are such due to their own actions, or lack of actions, and therefore “people

with negative characteristics such as fatness should be punished, avoided, and stigmatized—in

short, they deserve anger and prejudice” (Crandall et al, 2001, p. 31). This pattern of belief has

broad implications for how we behave toward others “If ideology leads a person to chronically

attribute controllable causality to others, he or she will tend to blame fat people for their weight

and stigmatize them for it” (Crandall, 1994, p. 884).

While weight stigma influences many aspects of overweight and obese peoples’ lives, it

is most impactful in the area of healthcare, where understanding, acceptance and support are

critical for diagnosis, treatment, and ongoing healthcare.


Anti-fat Bias in Healthcare

Anti-fat bias has significant consequences but nowhere is it more impactful than in the

healthcare system, a place where solutions should be forthcoming and health supported. It is all

too common for the obese person to be shamed, blamed and told by healthcare professionals,

either implicitly or explicitly, that whatever the presenting problem, the underlying cause it that

“you are too fat, go away and lose weight and then come back and see me” (Teachman &

Brownell, 2001).

Explicit and Implicit Anti-fat Bias in Healthcare

There is a multitude of social consequences that are significant and pervasive as a result

of the obesity epidemic and the rising anti-fat bias of those interacting with the obese population.

Weight-based stigmatization shows up in multiple areas, including in work settings where

overweight and obese people have been treated poorly by coworkers and employees and

denied jobs and promotions; educational settings in which obese students have been

ridiculed by peers, viewed negatively by educators, and even dismissed from college

because of their weight; and healthcare environments, where obese patients confront bias

from health care professionals including doctors, nurses, dieticians, and mental health

professionals (Puhl & Brownell, 2006, p. 1802).

In a study of 400 doctors, one of every three listed obesity as a condition to which they

respond negatively. They ranked it behind only drug addiction, alcoholism, and mental illness.

Attributes that they associated with obesity included: noncompliance, hostility, dishonesty, and

poor hygiene (Friedman & Puhl, 2012).

A study by Puhl and Brownell reported that physicians and family members were the

most frequent sources of weight bias (2006). Techman and Brownell indicated that “…health


care specialists have strong negative associations toward obese persons, indicating the

pervasiveness of the stigma toward obesity (2001, p. 1525). The tendency to make appearance-

related comparisons appears to play a central role in anti-fat attitudes, which is consistent with

other group-based prejudice research (O’Brien, Hunter, Halberstadt & Anderson, 2007).

Though there is widespread anti-fat bias in the culture, it is especially salient in

healthcare settings and with the healthcare providers, doctors, nurses, medical technicians,

physical therapists and other staff who directly care for the patient. A study by Sabin, Marini and

Nosek (2012) indicated that “MDs, on average, also showed strong implicit anti-fat

bias…reported a strong preference for thin people rather than fat people or a strong explicit anti-

fat bias” (p. 1). They concluded that “…strong implicit and explicit anti-fat bias is as pervasive

among MDs as it is among the general public.”

Eenfeldt, MD reported an incident that is representative of many patient/doctor

interactions.

…a patient asked her doctor about possible medical causes for her weight gain. The

doctor told her not to worry about such things. Weight gain was just a matter of how

much food she ate. Then the doctor asked her if she had seen pictures from the

concentration camp Auschwitz, and if she had seen any fat prisoners there (2013).

Since body size and weight have significant impact, even in those cases where there

might be underlying medical conditions, there is still the tendency to judge and respond from

these explicit and implicit anti-fat biases when interacting with a patient appearing either

overweight or obese. One such medically based condition is a common but little recognized fat

disorder, lipoedema. Medical professionals on the whole do not know about lipoedema,

generally failing to recognize the signs and symptoms leading to misdiagnose as obesity. There


is some progress in Europe, but an evident lack of knowledge more so in the United States.

There is research available mostly in Germany and somewhat in the U.K.

Lipoedema: Genetic Inherited Fat Disorder

Obesity stigma has significant impact for women with lipoedema, a little known and

oftentimes misdiagnosed inherited genetic fat disorder that affects 11% of women of all sizes,

from the extremely thin to the morbidly obese. Lipoedema is characterized by localized fat that is

bilateral, symmetrical and usually from the waist to just above the ankles. Unlike the “normal”

fat of obesity, lipoedemic fat cannot be lost through diet and exercise (Herbst, 2012).

Media’s influence represents and reinforces overweight and obesity as the result of poor

life-style choices such as diet and exercise and exacerbates the stigma and discrimination that’s

likely to occur when treatment is sought, even though lipoedema is a medical condition and not

necessarily a result of inappropriate food choices. Body size and weight matter, judgment and the

resultant stigma can be present, whatever the cause might be.

Impact of Anti-fat Bias on Women’s Health

Overweight and obese women report being treated disrespectfully by health professionals

because of their weight. One study found that 53% of overweight and obese women reported

receiving inappropriate comments about weight from their doctors (Puhl & Brownell, 2006).

Obese patients who report perceptions of weight discrimination avoid seeking routine preventive

care such as cancer screenings (Sabin, Marini & Nosek, 2012). This is most problematic for

those with lipoedema, since the appearance of obesity is from a medically based condition.

Survey Responses

I am in the midst of administering a survey about healthcare experiences to women with

lipoedema. Their responses offer evidence to this perspective with many indicating significant to


severe impact from lack of diagnosis, unclear treatment options, and interactions with healthcare

professionals ladened with anti-fat bias. In many cases they reported explicit anti-fat bias from

their healthcare professionals.

In one such case, a woman with both lipoedema and obesity reported, “I repeated myself

over and over, and was told I am fat and need to lose weight without any regard for my whole

well being and the shape of my legs. I am still experiencing this.” And in another instance, “I

have been denied other treatment in the past - left in chronic pain for 15 years by a gynecologist

who refused to treat me due to my size.” And a third woman reported, “The journey to get a

diagnosis was frustrating and demeaning. I was blamed and shamed and made to feel I was

cheating and the weight was my own fault. I thought things would be a lot better after the

diagnosis but I quickly found having Lipoedema as opposed to lymphoedema precluded me from

lots of treatment and it was difficult to get advice, information and treatment.” Unfortunately, in

many instances, lack of diagnosis and treatment leads to further complications.

Teachman and Brownell (2001) reported that healthcare professionals are exposed to the

same social messages about obese persons as is the general population and are even more aware

of the negative health consequences of obesity. The evidence suggested that negative attitudes

expressed by medical professionals are directed not just toward obesity as a health condition, but

also against people who are obese (p. 1525). This corroborates the underlying discomfort, shame

and blame reported by patients in interacting with their medical professionals.

Anti-Fat Bias: Awareness, Resiliency and Tools for Healing

As detailed above, the obesity crisis is on the rise. Various research into interventions is

being conducted as solution building for dealing with anti-fat bias and stigma associated with

obesity and body size. Since stigma and anti-fat bias is a multi-dimensional problem, a multi-


dimensional approach to changing it is needed. Components suggested and being researched as

viable options include education for healthcare professionals, social awareness and social support

on a relational level, and personal individual awareness raising and mindfulness meditation.

Healthcare Awareness: Educating Healthcare Professionals

A study recently conducted in the U.K. by Swift, Tischler, Markham, Gunning,

Glazebrook, Beer and Puhl (2013) at the University of Nottingham suggested that education by

way of film helped to improve awareness in medical students and nutrition counselors in

training. Two 17-min films were shown to the intervention group in a controlled study; ‘Weight

Prejudice: Myths and Facts' and ‘Weight Bias in Healthcare'. Both films have been developed

by the Rudd Center for Food Policy and Obesity at Yale University, New Haven, CT, USA.

Both films employ several different strategies to promote stigma reduction, including

i) attributions of weight controllability

a. (e.g. communicating the complex etiology of obesity, of which individual

behaviour is only one contributing factor);

ii) empathy induction

a. (e.g. showing viewers personal experiences of weight stigmatization and how

it affects individuals), and

iii) debunking weight-based stereotypes

a. (e.g. directly challenging common weight-based stereotypes with scientific

evidence and examples of obese persons whose behaviours are non-

stereotypical).

(Swift, Tischler, Markham, Gunning, Glazebrook, Beer & Puhl, 2013, p. 93).


Their study confirmed the existence of weight bias among trainee healthcare

professionals, on both implicit and explicit attitude measures. Additionally, there were strong

beliefs of controllability that obesity is under a person's control. Explicit attitudes and beliefs

about obese persons significantly improved after viewing the films. Participants’ evaluations

were positive.

The researchers concluded that the brief, educational films did indeed improve trainee

healthcare professionals' attitudes toward obesity. Weight bias is an issue of critical importance

that the educators of tomorrow's healthcare professionals cannot afford to ignore.

Social Awareness: Social Support

According to Puhl and Brownell (2006), when someone believes that obese people are

responsible for their fatness, he or she will blame and stigmatize them. The effect of dealing with

or trying to avoid dealing with these kinds of day-to-day interactions often results in isolation for

obese people. Social interaction and social support, often in like-minded communities, can help

in mitigating the consequences of anti-fat bias and weight stigma.

Several coping strategies have been reported to be frequently used to alleviate stigma

included heading off negative comments, using positive self-talk, and seeking social support

from others. Coping strategies to deal with stigma have important implications for emotional

functioning. Among women, positive coping strategies, including positive self-talk and obtaining

social support, were related to healthier psychological adjustment and increased self-esteem

(Puhl & Brownell, 2003).

Members of stigmatized groups may cope with identity threat by approaching, or

identifying more closely with, their group. Groups can provide emotional, informational,

and instrumental support, social validation for one’s perceptions, social consensus for


one’s attributions, and a sense of belonging. Group identification is positively correlated

with self-esteem among stigmatized groups (Major & O’Brien, 2005, p. 405).

Face to face support groups have proven successful for many years, most especially noted

are the 12-Step programs of Alcoholics Anonymous and Overeaters Anonymous. Social media

and online support groups have made connection and support more easily accessible globally and

many exist today. Specialized groups attending to specific populations have grown such as

several particular to those with lipoedema. Participation and results for self-esteem, self-

compassion, and social support can be further studied to evaluate for successful intervention in

developing health coping strategies in response to weight stigma.

Personal Awareness: Mindfulness, Compassion & Advocacy

Many obese people hold negative weight attitudes towards themselves and others. They

react to external bias by applying these same negative stereotypes to themselves. Puhl and

Brownell (2003) reported that “weight bias occurs irrespective of an individual’s own body

weight, and that overweight people themselves tend to express bias” (p. 215). Mindfulness

meditation research has demonstrated such conditions as self-awareness, self-regulation, self-

compassion and overall positive emotional well-being as a result of mediation practice.

Mindfulness refers to a process of self-regulation of attention to the present moment.

According to Eberth and Sedlmeier “mindfulness meditation entails sitting quietly and is mainly

characterized by just observing one’s experiences, not creating or modifying them” (2012, p.

174). Someone engaged in mindfulness meditation focuses their conscious awareness of their

immediate experience with an attitude of curiosity, openness, and acceptance.

Jon Kabat-Zinn established one of the first Centers for Stress Reduction using

mindfulness meditation at the University of Massachusetts Medical School. His research


reported that the most direct evidence for the benefits of mindful awareness and attention has

come from research demonstrating that mindfulness training is related to positive psychological

and physical outcomes (1990).

There are questions still to be addressed about whether, and to what extent, coping efforts

influence emotional well-being and are helpful in offsetting the impact of stigmatizing

experiences (Brown & Ryan, 2003). Mindfulness meditation can be one of several coping

strategies to deal with bias and increasing emotional well-being for those obese people

experiencing weight stigma. Additional research is needed to address the relationship between

weight stigma and mindfulness meditation, and how both of these experiences influence

psychological and behavioral outcomes.

Conclusion: Words of Wisdom from Oprah Winfrey

As detailed in this paper and other seminal work cited, obesity is a complex and multi-

layered issue necessitating continued research delving into core causes of the depth of prejudice

and stigma that exists towards obese people. Growth, understanding and self-advocacy stand

firmly in light of the barrage of negativity, none so apparent than with the media personality,

Oprah Winfrey.

Perhaps as one of the most noticeable media personalities caught in the limelight of body

image is Oprah Winfrey who has generated ongoing buzz in the media. All forms of media have

documented her various body size ups and downs with numerous diet and exercise programs

over the years. Despite her undeniable presence and position of power in the public discourse,

she too has had to deal with stigma and anti-fat bias.

Rather than be victim to the media’s barrage of judgment on her body, Oprah’s process

reflects one of growth, acceptance and courage and are demonstrated in her own words.


Are you ready to stop colluding with a culture that makes so many of us feel physically

inadequate? Say goodbye to your inner critic, and take this pledge to be kinder to yourself

and others. This is a call to arms. A call to be gentle, to be forgiving, to be generous with

yourself. The next time you look into the mirror, try to let go of the story line that says

you're too fat or too sallow, too ashy or too old, your eyes are too small or your nose too

big; just look into the mirror and see your face. When the criticism drops away, what you

will see then is just you, without judgment, and that is the first step toward transforming

your experience of the world (2013).

While the stigma of obesity has serious impact, there is recourse in learning to raise

awareness as to media’s influence. Change can happen by educating healthcare professionals

about the impact that stigma causes and about various medical conditions such as fat disorders,

making visible the ways in which acting on anti-fat bias hurts both patients and those attempting

to treat them and by helpful coping strategies such as mindfulness meditation and self-efficacy.


References

Ahern, A. L., Bennett, K. M., Kelly, M. & Hetherington, M. M. (2011). A qualitative exploration of

young women’s attitudes towards the thin ideal. Journal of Health Psychology, 16(1), 70-79. doi:

10.1177/1359105310367690

Bessenoff, G. R. & Sherman, J. W. (2000). Automatic and controlled components of

prejudice toward fat people: Evaluation versus stereotype activation. Social

Cognition, 18(1), 329-353

Brewis, A. A., Wutich, A. Falletta-Cowden, A., & Rodriguez-Soto, I. (2011). Body norms and

fat stigma in global perspective. Current Anthropology, 52(2), 269-276.

Brown, K. W. & Ryan, R. M. (2003). The benefits of being present: Mindfulness and its role in

psychological well-being. Journal of Personality and Social Psychology, 84(4), 822–848.

Brown, P. J. & Konner, M. (1987). An anthropological perspective on obesity. Annals of the New

York Academy of Sciences: Human Obesity, 499, 29–46.

Crocker, J., Cornwell, B., & Major, B. (1993). The stigma of overweight: affective

consequences of attributional ambiguity. Journal of Personality and Social Psychology,

64(1), 60-70.

Crandall, C. S. (1994). Prejudice against fat people: Ideology and self-interest. Journal of

Personality and Social Psychology, 66(5), 882-894.

Crandall, C. S., D'Anello, S., Sakalli, N., Lazarus, E., Nejtardt, G. W. & Feather, N. T. (2001).

An attribution-value model of prejudice: Anti-fat attitudes in six nations. Personality and

Social Psychology Bulletin, 2001 27(1), 30-37. DOI: 10.1177/0146167201271003

Dion, K. K., Berscheid, E., & Walster, E. (1972). What is beautiful is good. Journal of

Personality and Social Psychology, 24, 285–290.


Eberth, J. & Sedlmeier, P. (2012). The effects of mindfulness meditation: A meta-analysis.

Mindfulness, 3, 174–189. DOI 10.1007/s12671-012-0101-x

Eenfeldt, A. (2013). Doctor: “No fat people in Auschwitz.” Diet Doctor: Real Food for Your

Health. Retrieved from http://www.dietdoctor.com/doctor-no-fat-people-in-auschwitz

Friedman, R. R. & Puhl, R. M. (2012). Weight bias: A social justice issue. Yale Rudd Center for

Food Policy and Obesity: Policy Paper. New Haven, CT: Yale University.

Goffman, E. (1963). Stigma: Notes on the management of spoiled identity. New York, NY:

Simon & Schuster.

Herbozo, S., Tantleff-Dunn, S. Gokee-Larose, J. & Kevin Thompson, J. (2004). Beauty and

thinness messages in children’s media: A content analysis. Eating Disorders: The

Journal of Treatment & Prevention, 12(1), 21-34. doi: 10.1080/10640260490267742

Herbst, K. L. (2013). Rare adipose disorders (RADs) masquerading as obesity. Acta

Pharmacologica Sinica, 33, 155-172.

Kabat-Zinn, J. (1990). Full catastrophe living: Using the wisdom of your body and mind to face

stress, pain, and illness. New York: Delacourt.

Katz, D. L. (2011). Is obesity bias evolutionary? The Huffington Post. Retrieved from

http://www.huffingtonpost.com/david-katz-md/is-obesity-bias-evolutionary-

_b_858435.html

Kurzban, R. & Leary, M. R. (2001). Evolutionary origins of stigmatization: The functions of

social exclusion. APA Psychological Bulletin, 127(2), 187-208.

Major, B. & O’Brien, L. T. (2005). The social psychology of stigma. Annual Review of

Psychology, 56, 393–421. doi: 10.1146/annurev.psych.56.091103.070137


O’Brien, K. S., Hunter, J. A., Halberstadt, J. & Anderson, J. (2007). Body image and explicit and

implicit anti-fat attitudes: The mediating role of physical appearance comparisons. Body

Image, 4, 249–256.

Puhl, R. M. & Heuer, C. A. (2009). The stigma of obesity: A review and update. Obesity 17(5)

941–964.

Puhl, R. M. & Brownell, K. D. (2003). Psychosocial origins of obesity stigma: toward changing

a powerful and pervasive bias. Obesity Review, 4(4), 213-27.

Puhl, R. M. & Brownell, K. D. (2006). Confronting and coping with weight stigma: an

investigation of overweight and obese adults. Obesity, 14, 1802–1815.

Puhl, R. M., Moss-Racusin, C. A. & Schwartz, M. B. (2007). Internalization of weight bias:

Implications for binge eating and emotional well-being. Obesity 15(1) 19-23.

Sabin J. A., Marini, M. & Nosek, B. A. (2012). Implicit and explicit anti-fat bias among a large

sample of medical doctors by BMI, race/ethnicity and gender. PLoS ONE 7(11): e48448.

doi:10.1371/journal.pone.0048448

Schwartz, M. B., Chambliss, H. O. N., Brownell, K. D., Blair, S. N., & Billington, C. (2012).

Weight bias among health professionals specializing in obesity. Obesity research, 11(9),

1033-1039.

Schwartz, M. B., Vartanian, L. R., Nosek, B. A., & Brownell, K. D. (2012). The influence of

one's own body weight on implicit and explicit anti‐fat bias. Obesity, 14(3), 440-447.

Soubry, A. (25 March 2013). Policy: Reducing obesity and improving diet. Department of

Health: U.K. Gov. Retrieved from https://www.gov.uk/government/policies/reducing-

obesity-and-improving-diet


Sturm, R. (July 2007). Increases in morbid obesity in the USA: 2000–2005. Public Health,

121(7): 492–6. doi:10.1016/j.puhe.2007.01.006

Swift, J. A., Tischler, V., Markham, S., Gunning, I., Glazebrook, C., Beer C. & ·Puhl, R. (2013).

Are anti-stigma films a useful strategy for reducing weight bias among trainee healthcare

professionals? Results of a pilot randomized control trial. Obesity Facts, 6(1), 91-102.

DOI:10.1159/000348714

Teachman, B. A., & Brownell, K. D. (2001). Implicit anti-fat bias among health professionals: is

anyone immune? International journal of obesity 25, 1525-1531.

Teachman, B. A., Gapinski, K. D., Brownell, K. D., Rawlins, M., & Jeyaram, S. (2003).

Demonstrations of implicit anti-fat bias: the impact of providing causal information and

the impact of providing causal information and evoking empathy. Health Psychology

22(1), 68-78.

Tiggemann, M., & Wilson-Barrett, E. (1998). Children’s figure ratings: Relationship to self-

esteem and negative stereotyping. International Journal of Eating Disorders, 23, 83–88.

Winfrey, O. (2013). Step away from the mean girls...and say bye-bye to feeling bad about your

looks. Beauty Pledge on Oprah.com. Retrieved from http://www.oprah.com/spirit/Sign-

the-Beauty-Pledge-O-Magazine-Beauty-Revolution-Pledge#ixzz2Q2hbQq7I

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Anti Fat Bias in Healthcare