More bad news about weight stigma in health professionals and soon-to-be health professionals
Trigger warning: Discussion of how doctors treat fat and eating disorder patients, including weight loss advice.
I’ve written here before about the ever-increasing number of studies showing just how biased healthcare professionals are against fat people and why that’s a major problem (apart from the obvious reasons, of course). Since then, a bunch of new studies have come out just adding to the list of people who hate us. There have been two in the last few weeks and I’d like to talk about them here. They were both published by the team at the Yale Rudd Center, which for all its faults, is the source of a huge proportion of the weight stigma research being done at the moment.
The first of the two studies looked at anti-fat stereotypes and biases in professionals specialising in treating eating disorders, including psychologists, therapists, social workers, dieticians, doctors, nurses, paediatricians, and a few other types of medical professionals. This was an anonymous online study that recruited participants through websites and mailing lists of major US Eating Disorder organisations and charities.
Despite the anonymity, there did appear to be some “social desirability” responding (e.g., answering to make themselves sound better (or less bad)). An overwhelming 94% of medical professionals thought treating obese patients with compassion and respect was important (one has to wonder about the other 6%!). Furthermore, 72% said that treating obese patients was professionally rewarding. Most reported feeling confident (88%) and professionally prepared (84%) to provide quality care to obese clients.
Despite this, 56% had personally heard or witnessed colleagues making negative comments about obese patients, 42% felt that ED-treating professionals had negative attitudes towards obese people generally, 35% thought practitioners were uncomfortable treating obese patients, and 29% reported that their colleagues had negative opinions about fat patients. The famous study where over 90% of people considered themselves to be “above average” drivers springs to mind here.
Their own responses to questionnaires about attitudes towards obese people showed moderate levels of anti-fat bias, although slightly lower than that seen in other professions. I particularly like the fact that on one of the stereotype questions, 50% of respondents felt that obese people were “insecure.” Gee, I wonder why. 55% thought that they overate, 38% that they were inactive, and 24% that they were unattractive. One-third said fat people had poor self-control. Generally, professionals with higher BMI themselves, or who had been working in the field for longer, were less likely to attribute obesity to behavioural factors, and had slightly lower fat-phobia scores.
I find it interesting that so many felt professionally equipped to “treat” obese clients. It is not clear from the write-up of this study whether this was in terms of treating EDs in obese patients or if they were talking about helping with weight loss. Most of the questions and responses sound more consistent with the latter, including only half believing that obese people could be successful in making behaviour change and half again believing that patients were motivated to change their diets. A whopping two-thirds did not believe obese patients were compliant with treatment recommendations, and only 24% were confident that obese people could maintain weight loss (which is actually quite high, given the evidence!). It’s also worth noting (though not entirely unsurprisingly) that higher anti-fat bias was associated with more pessimism about treatment outcomes.
Let’s forget for a moment that “treatment” means weight-loss and this is almost definitely a damaging “intervention” that shouldn’t be undertaken in the first place. What’s important is that these people think that this treatment approach is good and right, but the more they dislike fat people, the less likely they are to think that they’re going to get anywhere with their clients. Now this raises the chicken and egg question: is it failed treatment experiences (the most likely outcome when it comes to weight loss attempts) that’s driving the anti-fat bias or is it just that the disdain for fat people and the buy-in to all of the negative stereotypes that make people less likely to predict treatment success? It’s known that negative expectations are generally linked to poorer outcomes. So if it’s the latter, the implications for other treatments, ones that are actually helpful and that might otherwise work, are very serious. The next study down helps to answer this question, but there’s one more thing I want to talk about before we move on.
One of the most interesting things about this piece of research is that it had an almost unprecedented drop-out rate for an online study, which the authors talk about in more detail. It is usual to be a little vague when inviting people to participate in a survey because you don’t only want people to respond who already have strong feelings in that particular area, which would skew the findings. This study was advertised as a study of professionals and practitioners treating eating disorders. They followed a link to the study website where they read more about the study and agreed to participate. 522 participants started the survey, but only 371 finished it. There was around a 10% drop out when participants were asked for information about themselves (completely anonymous, remember), the first being gender (about 8% drop out), and then height and weight (another 6% or so dropped out). Questions about what kinds of patients they treat were fine (so the drop-out can’t be put down to professionals who treat EDs (anorexia, bulimia, BED, etc.) but don’t “treat” obesity, but when the first questions asking about their beliefs in fat stereotypes came up, another 10% decided they didn’t want to continue. A few more dropped out at each set of stigma questions thereafter, in particular, when asked about their opinions of their obese clients (right at the end), giving a final drop out of 39%. It is possible that people with more stigmatising beliefs may have dropped out to avoid answering these questions, meaning that the final results under-report weight stigma in this group of professionals, but given the anonymous nature of the study, it’s still a little odd.
Finally, it’s well known that weight stigma in healthcare providers can affect treatment outcome of all conditions, may be damaging in its own right, and can have knock-on effects with respect to healthcare avoidance. In terms of eating disorder professionals, though, fear of fat may have an additional negative impact on safe, effective treatment for individuals with both high weight (you binge eat, but you’re still fat, so here’s a weight-loss diet) and low-weight EDs (I mean, anorexia is bad and all, but we wouldn’t want them to get FAT!!!). All in all, none of this is good.
The second study used similar methods, including anonymity, but contacted a small sample of postgraduate trainee healthcare professionals. The 107 participants were working toward qualifying as physician associates or clinical psychologists or medics undertaking their psychiatric residency. As usual, there were some very worrying statistics here. Half of the sample agreed that their peers had negative attitudes towards obese patients. Most had heard fellow students (63%), professors or instructors (40%), and other healthcare providers (65%) making derogatory jokes about fat people. Of course, only 3% agreed that it was ok to make fat jokes. And even fewer than believed that fatness was due to people’s own negligence and this made them deserving of such treatment. It’s funny how nobody thinks it’s ok, but everybody does it. Again, perceptions of motivation and “compliance” in obese “patients” was generally not good, and just a quarter felt treating them was professionally rewarding or that counselling or working with them was enjoyable. Yet only 13% admitted to actually disliking interacting with their fat patients.
What I found particularly interesting, though, is that the researchers looked at what factors (age, gender, ethnicity, BMI, self-esteem, their own body weight or shape issues, and anti-fat bias) were strongly associated with their expectations of treatment compliance or success. The only one that mattered (statistically speaking) was anti-fat bias. The greater the dislike, the lower expectations. Given that these are people who are not yet fully qualified and are likely to have had only a small amount of exposure to these situations, this goes some way to answering the chicken and egg question. The relationship between distaste and pessimism isn’t a result of years of failed treatment; it seems to be there at the outset.
There’s a theory that connects anti-fat bias with blame. If people think that fat people are fat through either personal character failings or just lack of self-respect, or both, then they will have a lower opinion of them. There’s certainly evidence from the stigma literature (and not just for weight stigma) that this moralistic relationship holds true. And this study found the same thing. Of all those factors tested (age, gender, yadda yadda yadda), compared with beliefs about how and why people get fat, none of them were associated with beliefs about a biological cause or a psychological cause, but anti-fat bias was strongly linked with believing it was because of behaviours, basically, greed and laziness.
Now, this might sound promising. Perhaps if we expand healthcare education to include more information about the complex causality of obesity (to include genes and environment, usually —why does nobody talk about how dieting makes you fat?!), then this would offset the moral judgment and reduce bias. So a bunch of researchers have tried it. There are a few examples in this review and a few more published since. They’ve used different methods: videos, lectures, all sorts, and they’ve all found the same thing: these interventions are very successful about changing beliefs. The students who receive the training generally have a much better understanding of obesity than those who don’t.
Unfortunately, though, they still don’t like fat people.
It seems, the theoretically understandable excuse that people’s distaste is simply a judgment on a perceived lack of personal responsibility in a society that values this trait is just that: an excuse. The apologists’ rationalisation of society’s sanctioned prejudice against fatties.