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Teaching About Diet and Exercise Promotes Anti-Fat Bias

Over the next little while, I will be taking a few days off and so I will be reposting some of my favourite past posts. The following article was first posted on Apr 19, 2010:

As blogged previously, health-care professionals including physicians, nurses, psychologists, dietitians, fitness professionals, medical students, and even health professionals who specialise in obesity are often biased against obese people.

This anti-fat prejudice has direct implications for the health of those struggling with excess weight as it can increase vulnerability for depression, low self-esteem, anxiety, suicidality, maladaptive eating behaviors, avoidance of physical activity, poorer outcomes in behavioral weight loss programs, and hesitation to seeking preventive health-care services.

Perhaps one reason why health professionals are particularly prone to anti-fat prejudice, may be because conventional health education curricula tend to focus primarily on the importance of “controllable” lifestyle reasons for obesity, with health promotion/public health programs typically emphasizing dieting and physical activity as the cornerstones of obesity treatment and prevention. (see my previous posting: Does the Focus on Prevention Promote Weight Bias?)

Thus, the predominant focus on personal control may well increase the notion that people with excess weight simply lack willpower or are gluttonous and lazy.

This hypothesis was now tested by Kerry O’Brien (Manchester, UK) and colleagues in a paper just published online in OBESITY.

University students (n = 159; 85% females) enrolled in a health promotion/public health bachelors degree program were randomised to take part in one of three 12-week tutorials:

1) A discussion of research on common causes and treatments for obesity emphasizing personal responsibility and control (e.g., overeating and lack of exercise).

2) A discussion of genetics (biological predispositions/heritability) and socioenvironmental (e.g., the calorie-dense food environment) reasons for obesity providing research evidence and discussion on uncontrollable causes of obesity.

3) A discussion of research on rates of hazardous drinking in young people (16–24 years), its consequences, drivers, and reduction approaches. (this was the control group).

Before and after tutorials, participants were examined both for explicit bias (e.g. “I don’t like fat people much”, “Fat people tend to be fat pretty much through their own fault”) and implicit bias (using a test that examines participants tendencies to associate negative attributes (e.g., “bad,” “lazy”) with “obese/fat people,” or positive attributes (e.g., “good,” “motivated”) with “thin/slim people”).

The researchers hypothesised that those receiving training about the controllable causes of obesity (e.g., diet and exercise) will display increased anti-fat prejudice relative to the control participants.

Conversely, the researchers expected that those receiving information on the uncontrollable causes of overweight and obesity (i.e., genetics, environment) will show reduced anti-fat prejudice.

And this is pretty much exactly what the researchers found: While, the diet/exercise condition (traditional obesity-related health curriculum) showed a 27% increase in motivated/lazy implicit anti-fat prejudice, the genes/environment condition exhibited a 27% decrease in implicit “good/bad” anti-fat prejudice and a decrease of 12% in implicit “motivated/lazy” anti-fat prejudice (there was no change in the alcohol education group).

Given this evidence that emphasising the importance of “controllable” risk factors for obesity in the education of health professionals can increase their anti-fat bias, it is perhaps time to rethink health professional educations.

As the authors point out:

…health educators should ensure that information on genetic, social and environmental causes of obesity, and their interactions, is delivered in a convincing manner along side traditional information on causes and treatments of obesity, such as diet and exercise.

This study not only has implications for professional education but also for public health campaigns that tend to focus exclusively on diet and exercise while avoiding placing as much attention on genetic and non-controllable risk factors.

My own experience in presenting our recently published aetiological framework for obesity assessment to health professional audiences is consistently met with an often palpable change in attitude amongst my colleagues, many of whom have explicitly thanked me for opening their eyes to the complexity of this condition.

As long as we as health professionals do not address anti-fat bias amongst our peers, those struggling with excess weight will continue to suffer the consequences.

Edmonton, Alberta

O’Brien KS, Puhl RM, Latner JD, Mir AS, & Hunter JA (2010). Reducing Anti-Fat Prejudice in Preservice Health Students: A Randomized Trial. Obesity (Silver Spring, Md.) PMID: 20395952


  1. “As long as we as health professionals do not address anti-fat bias amongst our peers, those struggling with excess weight will continue to suffer the consequences.”

    Couldn’t have said it better–Thank you!

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  2. You might want to broaden that education to the general public. When people feel free to sneer at and make loud, nasty comments to perfect strangers, there is clearly a problem.

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  3. You are correct that the underlying emote to reject the obese is significant. Even with a 50% obese pop, we will continue to see a social separation among those able to control their behavior to suit their needs and those that cannot. It is this lack of discipline in health bahaviors that causes many to judge and hold a bias.

    I meet with doctors weekly and many tell me they do not feel comfortable addressing weight, even when they know it is the underlying cause of their patients condition. They feel it will unfairly judge their patient and open the door to lawsuits.

    We might consider skipping the medical community and going with parks and recreation to assess and identify residents that could use help with nutrition/exercise and provide free memberships and training at local community fitness centers. Set up a strategy for support similar to drug addiction.

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  4. Arya, thank you for the excellent study showing that belief in uncontrollable causes of overweight and obesity reduces anti-fat prejudice in health promoters. Ironically, in my experience, so much can be accomplished in an obesity treatment by educating the PATIENT as to the CONDITIONED nature to their strong food cravings. When individuals learn this, they are empowered. It seems individuals have the same capacity to remove prejudice, in this case of themselves. So much recent work speaks volumes to the uncontrollable nature to “hypereating”. This information would be valuable to disseminate amongst obese populations in the family doctors office. Should we write an education piece for patients?

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  5. Mavis, “those able to control their behavior to suit their needs and those that cannot?” I’ve known a few obese people, and yes, some have that problem. Maybe even the majority. But others do not. And even the ones with eating disorders are often doubly damned by the uncontrolled factors you’re ignoring.

    My girlfriend eats more healthily and is more physically active than most of her skinny peers and never loses weight. Is she not snorting enough cocaine maybe? Her problem is some biological, inborn tendency to accumulate fat far in excess of what she should. Because of the kind of ambitious, hard-working person she is, I’m sure she’ll overcome it. But if you think she’s close to 200 pounds because she has an eating disorder, you aren’t paying attention.

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  6. It’s useful to have evidence for the psychological effect that focusing on controllable factors reinforces bias. On the other hand I’m not sure I go along with the apparent consensus here that focusing on what we can control is therefore something to avoid in education. I don’t think it would be too difficult to amass psychological evidence to also support the theory that focusing on what you can control is more effective in making desired changes than focusing on factors outside your control.

    The question is not whether we should focus on controllable or non-controllable factors in education, the the question is how we do a better job understanding and teaching which is which, and how we best control the factors within our power while not making the naive assumption that everyone has the same capacity or circumstances to make the same changes.

    It doesn’t make any sense for educators to deliberately swing the pendulum between extremes of self-responsibility and external determinism just because the social fashion and popular perception of a condition changes. Obesity is still unhealthy in many people, and prejudice is still prejudice, regardless of the prevailing cultural perceptions. We still need to acknowledge both the individual responsibility and the external circumstances that promote unhealthy conditions.

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  7. Clearly the genes alone nor environment alone are the cause of obesity. Thus, applying a binary approach as these researchers did has little real world relevance. Why not test whether a real education about the interaction between genes and environment changes anti-obesity sentiments? Is that not the way we should be educating people.

    From a biological perspective it is going to be very difficult to reverse the current level of obesity (I don’t see most people sticking to an hour of exercise a day in combination with low calorie diet and constant weight monitoring, the proven behaviors needed to maintain weight loss) Instead a focus on prevention is greatly needed. We know that prevention is possible, since our major genetic make up has not changed within the last 5,000 – 10,000 years, while our environment and behaviors certainly have.

    This is not to say that obese individuals are ignored, but the focus should shift from weight loss to a healthy lifestyle (i.e. regular exercise) which will do plenty to counteract many of the comorbities associated, but not necessarily caused by obesity. If I was to suggest a prejudice it would be against those insist on living an physically inactive lifestyle.

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  8. Todd I. Stark says “I’m not sure I go along with the apparent consensus here that focusing on what we can control is therefore something to avoid in education.”

    The article does not suggest to stop teaching professionals about the controllable causes and treatments of obesity, but to “… ensure that information on genetic, social and environmental causes of obesity, and their interactions, is delivered in a convincing manner along side traditional information on causes and treatments of obesity, such as diet and exercise.“

    In other words, teach both controllable and uncontrollable factors equally. Teaching one or the other alone is a disservice to health professionals and their patients. But I do agree with you that the goal of health education on obesity should focus on “teaching which is which, and how we best control the factors within our power while not making the naive assumption that everyone has the same capacity or circumstances to make the same changes.”

    I think the problem is when educators (or anyone for that matter) see only one side, or think there is only one cause for a condition like obesity, then predjudice and judgement of those not living up to that one standard increases. If people thought that there are multiple possible causes and different levels of ability to respond to obesity, then there might be more understanding and support for those trying to do something about their condition.

    I know from experience there is nothing more unmotivating then to be looked down upon because you are different or do not meet someone’s ideal, and to be told it’s your fault, especially when you try and nothing works.

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  9. What I find amazing is that perfect strangers can look at a given heavy person and KNOW that that person is just a lazy glutton without any underlying medical factors. There might be some few people who have medical problems, but that individual that they are looking at certainly is not one of them!

    This applies to doctors in spades. I have never seen a study where an obese patient is thoroughly examined for occult infections, hormonal suboptimum levels (Note: this is NOT the same is “within normal limits!”), depression, or the host of conditions that affect weight. Only when all is well otherwise is the obese patient “treated” with diet and exercise advice.

    Many people report that when they tell their doctors how much they eat and exercise they are called liars. To their faces.

    Can’t win for losing….

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  10. People have many prejudices and prejudice against fatness is just one of them. Some we are aware of. Some we are not. I think that prejudice against fatness is just part of a bigger prejudice against unattractiveness as we live in a culture that idolizes movie stars, etc who are beautiful (and thin) and hence the prejudice against fatness will likely never go away. What does seem changeable is the awareness that one is prejudiced and this is partly what this study speaks to.

    We cannot change how attractive we are,( without going to great lengths such as plastic surgery – which some people do) , but we overtly know that we prefer attractive people to unattractive folks. What’s different when someone is obese, is that we have been conditioned to think it is their own choosing that they have become fat. With beauty we know we have been born lucky or unlucky, as the case may be. We know it is not a choice and so, as health professionals, we don’t feel justified in “educating” people how to be more attractive. None of these things have anything to do with health of course. When a person is disliked because they are unattractive, or fat, there are of course psychological consequences and even behaviours that fall out of that.

    I think that we really need to
    1. focus on bringing the unsaid issues out into the open – like the belief that folks choose to be fat
    2. focus on what our patients can do to be as healthy today as they can be (not relying on a loss of X pounds in the future)
    3. recognizing how our own prejudices lead us to certain behaviours when dealing with our patients.

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  11. @Katja: Defintely not a concious choice, unconscious perhapsin cases of past sexual trauma- but those cannot be considered “choices” either – in fact people wi abuse histories often have histories of severe weight cycling.

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  12. Personally I chose to be overweight. Over the course of a few years I steadily decreased my activity levels and increased the amount of bread, pasta, potato chips and other processed foods relative to real foods in my diet.

    The result: 55lbs of weight gain.

    One day I looked at myself and said this isn’t right. So I cut all processed foods and increased my activity levels a small amount. It tool about 1.5yrs for all that weight to come off, but it wasn’t ‘hard’. I didnt calorie count or slave at the gym. I just stopped eating terrible food and became a bit more active. Side benefit of more or less eliminating my depression, and sleep problems was a welcome addition.

    Not saying I represent everyone, but I see a great number of overweight people making very bad food choices. Once you justify things like frozen pizza, going out to for meals frequently, pasta dinners, etc then you have given up your most powerful weapon against weight gain – what you put in your body. It is a tough battle after that.

    And yes ‘skinny’ people often make similarly bad choices. They are lucky in that it hasn’t reacted poorly with their physicality (yet), you may not be.

    Some people are born into money, some of us have to work hard and control our spending more strictly. If I spent like a wealthy person in would be devastating to my long term well being, similarily – if I ate like a person lucky enough to not gain weight from processed garbage then it would also be devastating.

    Control what you can control. It will often help correct the things beyond your control as well.

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  1. Better Training Needed to Curb ‘Fatism’ Within the Health Professions, Study Finds « Nursing Notes - [...] Teaching About Diet and Exercise Promotes Anti-Fat Bias ( [...]

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