Obesity Bias Among Healthcare Trainees

Published: January 21, 2014

Bias against obese individuals has received some very public attention during the past year. Most recently, Jennifer Lawrence, a young film star, suggested in an interview with Barbara Walters that calling people fat should be illegal). Earlier this past year, Dr. Peter Attia gave a TED talk questioning conventional wisdom about the causes of diabetes, in which he issued a mea culpa for the attitudes he held towards obese patients when he was a young surgeon-in-training.

In the less glamorous world of academe, an article appearing in the journal Obesity examines a topic related to Dr. Attia’s apology—obesity bias among healthcare trainees. In the article, Dr. Rebecca Puhl and colleagues at the Rudd Center for Food Policy and Obesity at Yale University examine obesity bias among healthcare trainees, and how that bias relates to attitudes towards patients with obesity, beliefs about the causes of obesity, and perceptions of treatment compliance and success among patients with obesity.

The researchers asked trainees from three types of healthcare programs—a Physician Associate (PA) program, a doctoral-level clinical psychology internship program, and a medical and psychiatry residency program—to complete several questionnaires assessing the attitudes and beliefs described above. Ninety-three percent of the trainees asked to participate did so.

Respondents reported on their own obesity bias using the FAT subscale of the Universal Measure of Bias (UMB), which asked respondents to indicate how much they agreed with statements such as, “Fat people are sloppy.” This approach to assessing bias, which psychologists refer to as an explicit approach, requires respondents to accurately report on their own biases. In contrast, other studies have used implicit approaches to assess obesity bias, in which respondents’ biases are inferred from behavior on computerized tasks. (For an example of an implicit approach to assessing weight bias, click here.) Implicit measures of bias are generally regarded as being less influenced by the respondent’s awareness of and willingness to report on his or her biases, the latter of which can be influenced by social desirability (a tendency to answer questions in a manner that will be viewed favorably by others). However, the authors state that previous research has shown that responses to the UMB-FAT subscale are not influenced by social desirability.

Respondents were also asked to report on: whether they perceived their peers and instructors to make derogatory comments or hold negative attitudes about patients with obesity; whether they viewed making jokes about patients with obesity as acceptable; whether they had negative attitudes about patients with obesity; whether they felt confident and prepared to treat patients with obesity; and what they perceived to be the causes of obesity (responses were later grouped into three types of causes—physiological, behavioral, or psychological); and whether they expected patients with obesity to be compliant and successful at making lifestyle (e.g., dietary) changes. Respondents were also asked to report on their own age, gender, ethnicity, and height/weight, as well as their self-esteem and their concerns about their own shape and weight.

Between one- and two-thirds of respondents agreed with statements that their peers and instructors made derogatory comments or held negative attitudes towards patients with obesity. Respondents who were more concerned about their own weight or shape were more likely to endorse witnessing obesity bias among their peers and instructors. A very low rate (less than 5%) of respondents agreed that they personally found making jokes about patients with obesity to be acceptable, with significantly higher rates of agreement among those who reported more obesity bias on the UMB-FAT scale. Approximately one-third of respondents reported negative attitudes towards patients with obesity (e.g., finding them frustrating) and expected lack of compliance and success at making lifestyle changes among patients with obesity. Significantly more negative attitudes and treatment expectations were found among those who reported more obesity bias on the UMB-FAT scale. Interestingly, given that Dr. Attia’s attitudes towards obesity changed with life experience, increasing age predicted less negative attitudes towards patients with obesity. Finally, respondents who reported more obesity bias on the UMB-FAT scale were significantly more likely to attribute obesity to behavioral causes (e.g., overeating), and respondents who attributed obesity to behavioral causes were in turn more likely to endorse negative expectations regarding lifestyle changes among patients with obesity.

The authors note several limitations of their study, including the fact that the respondents were neither a random nor representative sample of trainees in all healthcare disciplines. They also note that they did not compare how respondents’ obesity bias compared to their bias towards other patient characteristics. When reading the article, I found myself wondering whether the same respondents who expressed doubts that patients with obesity would be successful with lifestyle change would also express doubts that, say, patients with lower back pain would comply with physical therapy. Importantly, the authors note the importance of future research examining whether obesity bias among trainees affects their actual interactions with patients, or patient outcomes. Patients with obesity deserve the same compassion, respect, and quality of care as any other patient. For one, the causes of obesity are incredibly complex, and assumptions about why a particular patient is obese are unlikely to be correct. Further, even if someone were “at fault” for their own obesity, that doesn’t mean we should alter how we treat them; we don’t withhold compassion from someone who broke their back while skiing, which most people would consider a choice. As the authors point out, training to reduce obesity bias among healthcare professionals, including trainees, is essential. Such training should include education on the complex causes of obesity and the difficulty of returning to and maintaining a normal weight after being obese.


Puhl RM, Luedicke J, & Grilo CM (2013). Obesity bias in training: Attitudes, beliefs, and observations among advanced trainees in professional health disciplines. Obesity.

photo credit: Melodi2 via Creative Commons