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The Intersection of Biased Mental Models, Stigma, Weight Bias, and Obesity

Carlos Crespo, professor at Oregon Health and Science University and Portland State University School of Public Health and vice provost for undergraduate training in biomedical research at Portland State University, moderated the first workshop’s third session. The session’s two speakers discussed the intersection of biased mental models, stigma, weight bias, and obesity, with a focus on workplace and health care settings.

In his introductory remarks, Crespo suggested that to guide their actions, people rely on mental models, which he likened to behavioral shortcuts or algorithms. He suggested that these algorithms are as good as the assumptions and biases on which they are based, which therefore inform a person’s actions, even subconsciously. Consequently, he argued, deconstruction of those assumptions and biases is important. Weight biases exist at the individual, institutional, and structural levels, he continued, where they become negative attitudes that are based on distorted beliefs. These attitudes and beliefs permeate multiple types of settings, he added, and provide the foundation for organizational norms. Those norms in turn lead to stereotypes that negatively impact the lives of people with obesity, he elaborated, such as through stigma, exclusion, and discrimination, and ultimately, health inequities. He reiterated the call to deconstruct and eliminate weight bias as an essential step in rewriting the narrative at all levels.

OBESITY STIGMA AT WORK: IMPROVING INCLUSION AND PRODUCTIVITY

Stephen Bevan, head of human resources research development at the Institute for Employment Studies in the United Kingdom, discussed obesity stigma and discrimination in the labor market and in worksites. He elaborated on two specific challenges—the obesity “wage penalty” for women, and the sometimes inadvertent internalization of weight stigma in worksite health promotion efforts. He also offered suggestions for ways in which employers and health care providers could improve work outcomes for people with obesity.

Bevan suggested that among people who characterize obesity solely as an individual issue of willpower and eating and activity habits, weight bias may be the last “acceptable” form of stigma and discrimination. Almost half (45 percent) of UK employers say they are less inclined to recruit candidates who have obesity, and people who have obesity experience lower starting pay, less hiring success, and lower coworker ratings of job performance and ability (Bevan, 2019). They are frequently regarded as having less willpower and resilience, he continued, and are less likely to be perceived as able leaders or as having career potential. Women with obesity, Bevan reported, are less likely to get customer-facing jobs and fare poorly in the “aesthetic labor market,” a term he explained refers to settings where appearance may be deemed more important than competence.

Bevan next referenced a literature review indicating that employment discrimination and stigma appear to be more common among women than men, with women being 16 times more likely to report weight-related employment discrimination (Bajorek and Bevan, 2020). These authors also found that 25 percent of women with overweight and obesity reported experiencing job discrimination because of their weight, and 54 percent reported being subjected to weight-based stigma from coworkers or colleagues (Bajorek and Bevan, 2020). These experiences are rarely challenged in workplaces, Bevan observed, and are instead regarded as outside the mainstream of diversity and inclusion practices and policies.

According to Bevan, research suggests that weight-based stigma in employment pervades every stage of the employment cycle, including recruitment and selection, the development of employee relationships and well-being, progression and promotion, employment retention, and unemployment. For people with obesity, the weight-based challenges at each stage influence their employment outcomes.

Bevan then turned to discussing the obesity wage penalty, the first of two specific challenges he would address. He reported that a 2016 review conducted by the UK government identified a 10 percent wage gap between people with obesity and those with average weight. Neither the contributors to this finding nor the direction of causality was explored, but he referenced prior research on employment that identified links among social determinants of health (including poverty and employment), health inequalities, and obesity (Marmot, 2020). Moreover, living with obesity is linked not only to lower wages and employment discrimination, but also to lower household income throughout life because of gaps in education, as well as poorer health (Lee et al., 2019). Elaborating on social determinants of health, he explained that they have been referred to as “the causes of the causes of ill health,” where the first type of “causes” encompasses the conditions in which people are born, grow, live, and work, while the second type consists of health risk factors such as smoking and poor diet (Walker, 2021).

Bevan cited “overwhelming” evidence of the greater effects of the wage penalty on women than on men, and said his group is studying its causes and impact. He reported that the average gap is estimated at 9–13 percent. He added that this gap is not just in annual earnings (Bajorek and Bevan, 2020). Rather, strong evidence suggests that living with obesity from childhood to adulthood is associated with an earning disparity throughout the life course. Bevan gave the example of a study finding that females who had obesity at age 16 had 34 percent lower household incomes at age 42 compared with women of normal weight in the same age cohort (Black et al., 2018). Bevan listed additional research findings: women’s earnings peak at a body mass index (BMI) of 20–22 and decrease

as BMI increases (one study detected a 4 percent drop in income within 4 years after a 1-point increase in BMI); mothers who have obesity earn almost 7 percent less than mothers of average weight (one study measured a 7.6 percent decline per child among single mothers with obesity); and older women with BMI > 40 kg/m² are more likely to have extended periods of sick leave and to leave employment early, after controlling for age and other health factors, with stigma and discrimination hypothesized as playing a role (Linaker et al., 2020).

Bevan moved on to review four proposed explanations for the wage penalty. First is the explanation of human capital differences, which purports that women with obesity have lower educational attainment and limited work experience and experience occupational segregation into occupations with less prestige (i.e., work that is lower paid, lower skilled, and lower status). A second explanation is life-course barriers: that women with versus those without obesity find it more difficult to shed the health and education inequalities of childhood and adolescence and risk living in lower-income households because they are less likely to marry or cohabit. The third health differences explanation, Bevan continued, suggests that women with obesity have more health conditions and comorbidities that affect their ability to find and retain work, leading to reduced functional capacity, increased use of sick leave, and elevated risk of premature withdrawal from the labor market for health reasons. A final explanation is stigma. Bevan explained that according to this view, women with obesity are subject to systemic discrimination in the job market and workplaces. As a result, they are relegated to low-paying jobs for which they may be overqualified and in which opportunities for job and pay progression are constrained while negative stereotypes and weight-based stigma are normalized.

The conclusion from some of this evidence, Bevan summarized, is that the multiple employment disadvantages already experienced by women with obesity in the labor market are being compounded by a pervasive wage penalty in a tangible way, established for many in adolescence and continuing throughout adulthood. He reviewed the projected effect of the wage penalty at the national level in the United Kingdom on annual earnings per woman, based on average earnings and a prevalence of obesity of 30 percent: a 2 percent wage penalty = a 500-GBP (Great British pound) reduction; a 5 percent wage penalty = a 1,250-GBP reduction; a 9 percent wage penalty = a 2,250-GBP reduction; and a 13 percent wage penalty = a 3,250-GBP reduction. At a macroeconomic level, these reductions translate to 2.3, 5.75, 10.35, and 14.95 billion GBP per year, respectively (Bajorek and Bevan, 2020).

Bevan turned to the second challenge to be addressed in his presentation: that well-intentioned workplace health promotion programs with a nutrition, exercise, or weight management component may inadvertently

reinforce obesity stigma by reinforcing the belief that overweight and obesity can be resolved through efforts, driven mainly by an individual’s willpower, to eat less and move more (Bajorek and Bevan, 2020). As a result, some people with obesity may internalize the stigma they experience in society, Bevan explained, or make them reluctant to participate in such workplace programs or access support, advice, or even psychosocial help from which they might otherwise benefit (Täuber et al., 2018). He pointed out further that encouraging competition or using incentives can produce negative outcomes for some workers, mainly those with obesity (Quintiliani et al., 2010).

In closing, Bevan outlined actions that governments, employers, the media, and health care professionals can take to reduce obesity stigma. He suggested that governments can be more intentional in considering social determinants of health, such as employment, when attempting to address health inequities, and can classify obesity as a disease so as to open more health care pathways for resources to address it. He also proposed designating people with obesity as a protected class to help empower employers to protect them. He added that employers could modify their human resources processes to reduce the risk of stigma and discrimination by including obesity more explicitly in the design, implementation, and evaluation of diversity and inclusion programs and policies. He reiterated the call for workplace health promotion programs to avoid reinforcing stigma and to involve employees in their design. He suggested further that health care professionals could do more to consider employment outcomes as a clinical outcome of care and to be cognizant of obesity comorbidities—particularly mental health comorbidities—as a barrier for workers. Finally, Bevan argued that the media could promote people-first language, use appropriate images, and avoid oversimplifying the causes of obesity in favor of descriptions that highlight their complexity.

Bevan offered a few comments about COVID-19, prefaced by an acknowledgment of the elevated risk of poor COVID-19 outcomes for people who have obesity, which he said has amplified stigma for some people. He urged vigilance in preventing this situation from exacerbating existing health and social inequalities, noting that some employers are not managing the return to physical workplaces with sensitivity to weight issues. Although an employer’s desire to conduct a risk assessment among its workforce is prudent, Bevan said, it is important to avoid characterizing obesity as a burden.

In summary, Bevan reiterated that the labor market and workplaces are arenas in which much of the intersectionality of obesity’s drivers and consequences plays out. Work is both an economic and a social act, he maintained, and many challenges associated with inequalities in social determinants of health become manifest in work settings.

HEALTH CARE SYSTEMS PERSPECTIVES

Keith Norris, professor and executive vice chair for equity, diversity, and inclusion at the David Geffen School of Medicine at the University of California, Los Angeles, discussed the perspectives of health care systems on obesity and suggested how those perspectives could be improved going forward. He prefaced his remarks by defining three key terms:

• Weight bias: negative attitudes toward and beliefs about others because of their weight
• Obesity stigma: a social sign or label affixed to an individual who experiences prejudice because of excess weight
• Weight-based discrimination: enactment of weight bias and stigma in any discipline or sector

Norris continued by conveying the narratives about eating less and moving more are commonly heard by patients with obesity. To a patient, he pointed out, these narratives make weight loss and management sound simple, but they may also convey that health professionals believe obesity is self-imposed, so they have no obligation to help the patient find evidence-based treatments. In reality, Norris suggested, the journey for many patients has been anything but simple; he urged mindfulness of the challenges faced by people living with obesity.

To illustrate the reality of bias and stigma experienced in health care by patients with excess weight, Norris shared the results of a survey of more than 100 postgraduate trainees in professional health disciplines (Puhl et al., 2014). For example, 50 percent reported that their peers tend to have negative attitudes toward patients with obesity. However, only 1 percent agreed with the notion that if a person develops obesity, it is that person’s own fault, so it is acceptable to make jokes about their weight, and just 3 percent agreed that it is acceptable to make jokes about patients with obesity. Yet despite the reportedly wide unacceptability of this behavior, Norris pointed out, other results of this survey indicate that it is pervasive in health care settings: 40–65 percent of respondents reported that they had heard or witnessed negative comments, jokes, or derogatory humor about patients with obesity from professors or instructors, health care providers, students, or residents. He added that about one-third of respondents said they felt frustrated with patients with obesity; a similar percentage expressed the view that patients with obesity can be “difficult to deal with”; and 13 percent reported a dislike for treating patients who have obesity.

With regard to respondents’ perceptions of patients with obesity, Norris continued, 21 percent saw no difference between patients with obesity and those with normal weight; 18 percent stated the view that patients with obesity

tend to be lazy; 33 percent said patients with obesity lack motivation to make lifestyle changes; and 36 percent reported that patients with obesity are often noncompliant with treatment recommendations. On the other hand, Norris said it was encouraging that 95 percent of respondents said it is important to treat patients with obesity with compassion and respect, although only 27 percent reported that treating patients with obesity is professionally rewarding.

Finally, Norris pointed out what he characterized as a disconnect whereby 80 percent of respondents expressed confidence in providing quality care to patients with obesity, yet only 57 percent said they felt professionally prepared to treat patients with obesity effectively. These results have been replicated in a few other surveys of 600–800 providers, he added, referencing one survey in which physicians expressed their general sentiments that patients with obesity are noncompliant, lazy, lacking in self-control, weak willed, unsuccessful, and dishonest (Puhl and Heuer, 2009). These views, Norris said in summary, indicate how the health care system interfaces with many patients with respect to weight.

Norris observed that although physicians say they want to do the best for their patients, they may harbor implicit biases that hinder achieving that goal. He referenced research suggesting a high level of anti-Black implicit bias and a strong antifat bias among physicians and researchers (Alegria Drury and Louis, 2002; Merrill and Grassley, 2008). According to Norris, bias plays out in ambivalence about treatment roles, less time spent with and less discussion with patients, more ascribing of negative symptoms to patients, less intervention, and reduced preventive health services and exams (Puhl and Heuer, 2009; Sabin et al., 2012).

Biases among members of the health care system become embedded in the system’s structures, Norris argued, and form weight-related barriers for patients navigating the system. He explained, for example, that patients with obesity may receive unsolicited advice about losing weight or inappropriate comments about their weight, or experience disrespectful treatment or inaccessible equipment and facilities because of their weight (Puhl and Heuer, 2009).

Norris reviewed the negative consequences of weight bias for patients, listing shame and guilt, anxiety, depression, poor self-esteem, and body dissatisfaction, all of which can lead to unhealthy weight control practices. He added that weight bias also negatively affects access to obesity treatment, educational attainment, employment opportunities, employment earnings, and quality of health care, ultimately leading to inequities in patient care (Puhl and Heuer, 2009). He explained that experiences of weight-based discrimination amplify psychosocial stress, which in turn triggers a reallocation of neuronal activity in the brain that leads to poor cognitive processing. For patients, he continued, this pathway initiated by structural biases can lead to suboptimal clinical outcomes as a result of internalized fear, shame,

guilt, poor self-esteem, anxiety, depression, mistrust of the health system, and inability to remember and implement health advice. Based on the way this bias operates, Norris maintained, health professionals tend to think of the patient and wonder, “What did you do to yourself?” A more appropriate question, he suggested, is, “What did society do to you?,” which he said takes social determinants of health and structural biases into account.

Norris next offered strategies for countering bias and discrimination based on weight, starting with overcoming unconscious or implicit bias. Bias is universal and manifests differently for each person, he asserted, adding that recognition of one’s potential for bias is a first step. He encouraged clinical settings to treat patients as individuals and with empathy, care, and respect instead of relegating them to particular categories to which labels and personal attributes are automatically assigned. To unravel the institutionalization of bias, Norris urged examining and revising health system policies and practices that perpetuate structural biases. He encouraged health care providers to recognize their roles as community resources and leaders for health equity. To not get involved is to choose to be passive, he stressed, which he equated with choosing to perpetuate structural biases and health disparities.

Norris urged that when caring for patients with excess weight, providers recognize their experiences with weight-related discrimination, weight bias–induced limitations on employment and educational attainment, mistrust of care, impaired cognitive processing from the additional psychosocial stress associated with their condition, and other comorbidities. What patients need, he stressed, is high-quality care, respectful treatment, empathy, compassion, support, and hope—not judgment, ire, or lecture. Such care builds trust, he said, and could reduce patients’ psychosocial stress and resulting strains on cognitive processing. Norris ended his remarks with a quote from Sri Sathya Sai Baba: “Before you speak, think—Is it necessary? Is it true? Is it kind? Will it hurt anyone? Will it improve on the silence?”

PANEL AND AUDIENCE DISCUSSION

Following their presentations, the two speakers engaged in a moderated discussion and answered participants’ questions. They covered the role of policy in addressing weight bias, medical education on caring for patients with obesity, sector-specific differences in the obesity wage gap, and worksite health promotion programs and weight stigma.

The Role of Policy in Addressing Weight Bias

Crespo began the discussion by asking the speakers to comment on the role of policy in addressing weight bias. Bevan replied that under

European law, employers must treat obesity as a protected characteristic and make reasonable adjustments to accommodate any associated impairments among employees. He supported a shift in emphasis from individual behavior change to policy interventions, recognizing the roles of obesogenic environments¹ and health inequalities in contributing to the development of obesity.

Norris remarked that laws and policies reflect the conscience of society, and suggested examining and modifying policies that may inadvertently promote weight bias and discrimination. It is easier to do this at the local institutional level, he acknowledged, where structures could be established to promote good behavior rather than demean negative behavior.

Medical Education on Caring for Patients with Obesity

Asked about medical training in caring for patients with obesity, Norris affirmed that a one-size-fits-all weight management plan is not the answer. The current emphasis in medical education is on individualized care, he explained, which involves shared decision making between clinician and patient to determine what changes and interventions would be best suited to the patient’s goals, lifestyle, and resources. Patients have a sense of the barriers to change they may encounter, he elaborated, and sharing those barriers helps clinicians tailor recommendations and determine when to refer patients to other colleagues or specialists who can help them pursue the goals.

Norris also posited that a common health care perspective is to overestimate the ability of clinical recommendations on lifestyle changes to impact weight loss. The reason is that weight gain results from multiple factors, some structural and societal in nature, which he explained are difficult to overcome with health care providers’ lifestyle change recommendations. He urged providers to be mindful of where they are intervening along the spectrum of factors that influence weight (i.e., mainly on relatively downstream factors) so they will have a realistic sense of their interventions’ potential to make a difference.

Sector-Specific Differences in the Obesity Wage Gap

Bevan reported that his group had observed the wage gap to be amplified in lower-skilled, lower-paid jobs in such sectors as hospitality and retail that are often customer facing, compared with professional white-collar roles. He added that the wage gap is an issue predominantly among females in these sectors.

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¹ “Obesogenic environment” is defined as “an environment that promotes gaining weight and one that is not conducive to weight loss” (Swinburn et al., 1999).

Worksite Health Promotion Programs and Weight Stigma

Bevan commented on the design of worksite health promotion initiatives, noting that U.S. employers generally bear the high financial burden of health care costs and are therefore incentivized to improve their employees’ health. For example, employers may conduct health risk assessments and collect biometric measures, which he argued can reinforce stigma if not messaged carefully. In the United Kingdom, he said, worksite health promotions tend to fall into two categories: those that help the employer compete in the labor market by offering a benefit to employees but are rarely evaluated in terms of health outcomes, and those that aim to reduce psychosocial risk and musculoskeletal strain through a more methodological approach that assesses and mitigates workplace risks, and measures such outcomes as serious absenteeism, presenteeism, and labor productivity. In both cases, Bevan contended, organizations make the mistake of regarding ill health of any kind as a burden and a risk to mitigate instead of focusing on what people can still do despite living with a chronic disease or condition. The latter perspective is more positively framed, he asserted, and is a step toward undermining stigma and discrimination.