Hostname: page-component-7b7567c8c-2rsb6 Total loading time: 0 Render date: 2026-11-12T08:40:19.007Z Has data issue: false hasContentIssue false
  • English
  • Français

Weight bias among public health trainees

Published online by Cambridge University Press:  10 November 2020

Kendrin R SonnevilleOpen the ORCID record for Kendrin R Sonneville[Opens in a new window],
Kelsey L Rose,
Nathalie J Lambrecht,
Mikayla R Barry,
Heidi M WeeksOpen the ORCID record for Heidi M Weeks[Opens in a new window] and
Cindy W LeungOpen the ORCID record for Cindy W Leung[Opens in a new window]
Kendrin R Sonneville*
Affiliation:
Department of Nutritional Sciences, University of Michigan School of Public Health, 3855 SPH I, 1415 Washington Heights, Ann Arbor, MI 48109-2029, USA
Kelsey L Rose
Affiliation:
Department of Nutritional Sciences, University of Michigan School of Public Health, 3855 SPH I, 1415 Washington Heights, Ann Arbor, MI 48109-2029, USA
Nathalie J Lambrecht
Affiliation:
Department of Nutritional Sciences, University of Michigan School of Public Health, 3855 SPH I, 1415 Washington Heights, Ann Arbor, MI 48109-2029, USA
Mikayla R Barry
Affiliation:
Department of Nutritional Sciences, University of Michigan School of Public Health, 3855 SPH I, 1415 Washington Heights, Ann Arbor, MI 48109-2029, USA
Heidi M Weeks
Affiliation:
Department of Nutritional Sciences, University of Michigan School of Public Health, 3855 SPH I, 1415 Washington Heights, Ann Arbor, MI 48109-2029, USA
Cindy W Leung
Affiliation:
Department of Nutritional Sciences, University of Michigan School of Public Health, 3855 SPH I, 1415 Washington Heights, Ann Arbor, MI 48109-2029, USA
*
*Corresponding author: Email kendrins@umich.edu
Rights & Permissions [Opens in a new window]

Abstract

Objective:

To explore explicit beliefs about the controllability of obesity and the internalisation of negative weight-related stereotypes among public health trainees.

Design:

Cross-sectional online survey assessing explicit beliefs about the controllability of obesity using the Beliefs About Obese Persons Scale (BAOP) and internalisation of weight bias using the Modified Weight Bias Internalization Scale (WBIS-M). Bivariate associations between BAOP and WBIS-M scores and demographic characteristics were examined using t tests or ANOVA with post hoc Tukey’s tests.

Setting:

School of Public Health at a large, Midwestern University.

Participants:

Public health students (n 322).

Results:

Relative to students who identified as male, those who identified as female had a stronger belief that obesity is not within the control of the individual (P = 0·03), yet had more internalisation of weight bias (P < 0·01). Greater weight bias internalisation was also seen among students who perceived themselves to be of a higher weight status (P < 0·001) and those who were at risk for food insecurity (P < 0·01).

Conclusions:

Public health trainees may be more attuned to the complexities of weight relative to trainees in other health-related fields, but are still susceptible to internalisation of negative weight-related stereotypes.

Keywords

Weight biasPublic healthWorkforce development

Information

Type
Short Communication
Information
Public Health Nutrition , Volume 24 , Issue 6 , April 2021, pp. 1566 - 1569
Check for updates
Copyright
© The Author(s), 2020. Published by Cambridge University Press on behalf of The Nutrition Society

Weight bias is widespread and poses a significant threat to both physical and psychological health, yet is under recognised as a public health issue(Reference Alimoradi, Golbonia and Griffiths1–Reference Hunger, Major and Blodorn4). Experiencing weight stigma is physiologically stressful, undermines the self-regulation resources needed to engage in health-promoting behaviours and contributes to poor mental health outcomes such as depression, anxiety, substance abuse and eating disorders(Reference Alimoradi, Golbonia and Griffiths1–Reference Hunger, Major and Blodorn4). Despite research highlighting the complexity of the biological, genetic and sociocultural factors influencing weight, as well as the physiological adaptions following weight loss that promote weight regain, public health messages often focus on personal responsibility and frame weight as highly controllable(Reference Puhl and Heuer3). Such messaging perpetuates negative weight-based stereotypes and, thereby, threatens core ethical and humanistic public health values(Reference Puhl and Heuer3,Reference O’Hara and Gregg5) and ultimately harms the intended recipients of the public health message.

The presence of weight bias among healthcare trainees and professionals across a range of disciplines has been well described(Reference Phelan, Burgess and Yeazel6). To our knowledge, however, no research to date has examined weight bias among the public health workforce. Understanding beliefs about the controllability of weight among public health trainees could inform workforce development initiatives that aim to reduce weight bias in public health practice. Furthermore, characterising the extent to which public health trainees internalise weight-biased beliefs could provide insight into how exposure to weight-biased content during training may negatively impact the trainees themselves. Accordingly, the aim of this study was to explore explicit beliefs about the controllability of obesity and the internalisation of negative weight-related stereotypes among public health trainees.

Methods

Participants were students of all levels at a Council on Education for Public Health-accredited School of Public Health at a large, Midwestern University. In October 2019, students were invited to complete a Qualtrics survey examining ‘beliefs and experiences of public health students on nutrition-related topics such as weight bias and food insecurity’ via emails from school-wide listservs. Students who completed the survey were entered to win one of fifty $25 gift cards. Only students who indicated they were 18 years of age or older and those who agreed their data could be reported were included in the analysis.

Participants completed the Beliefs About Obese Persons Scale (BAOP)(Reference Allison, Basile and Yuker7), an eight-item measure designed to assess explicit beliefs about causes and controllability of obesity. The BAOP uses a six-point scale (–3 to 3, not including 0), with a possible score range of 0–48 (items summed plus 24) and higher scores indicating a stronger belief that obesity is not within the control of the individual. To examine how beliefs about negative weight-related societal stereotypes apply to oneself, participants completed a modified version of the eleven-item Weight Bias Internalization Scale (WBIS-M)(Reference Pearl and Puhl8), which is applicable to individuals across different body weight statuses. The WBIS-M uses a seven-point scale (1–7) that is averaged (possible score range of 1–7) with higher scores representing greater internalisation of weight bias. Students also provided responses to demographic questions assessing self-identified gender, race/ethnicity, perceived weight status, risk of food insecurity using two-items adapted from the USDA Core Food Security Module(Reference Gundersen, Engelhard and Crumbaugh9), degree programme and academic department. Bivariate associations between BAOP and WBIS-M scores and demographic characteristics were examined using t tests or ANOVA with post hoc Tukey’s tests.

Results

Among the 322 students in our analytic sample, the mean (sd; range) BAOP and WBIS-M scores were 22·89 (7·79; 6·0–42·0) and 3·12 (1·39; 1·0–7·0), respectively. Internal consistency of the BAOP in this sample was acceptable (α = 0·72), and the internal consistency of the WBIS-M was excellent (α = 0·93).

Descriptive characteristics of the sample and results of bivariate analyses are shown in Table 1. We observed significant differences in BAOP and WBIS-M scores according to gender. Relative to students who identified as male, those who identified as female had a stronger belief that obesity is not within the control of the individual (BAOP: 23·25 v. 20·68, P = 0·03), yet had more internalisation of weight bias (WBIS-M: 3·19 v. 2·63, P < 0·01). Greater internalisation of weight bias was also seen among students who perceived themselves to be of a higher weight status (4·12 v. 2·74, P < 0·001) and those who were at risk for food insecurity (3·53 v. 3·02, P < 0·01). No significant differences in BAOP or WBIS-M scores were seen according to race/ethnicity.

Table 1

Sample characteristics and bivariate associations with controllability of obesity and weight bias internalisation (n 322)

a Higher BAOP scores represent the belief that obesity is not within the control of the individual.

b Higher WBIS scores represent greater internalisation of weight bias.

c Bivariate associations between BAOP and WBIS-M scores and demographic characteristics were examined using t tests or ANOVA.

d To protect the anonymity of the small number of students who identified as a gender other than male or female (n 5), mean BAOP and WBIS-M scores for this group are not reported and are excluded from the bivariate analyses for gender.

e Students who wrote in their race/ethnicity as Middle-Eastern were classified as White, non-Hispanic; students who indicated they were both White/Caucasian and Hispanic were classified as Hispanic; students who indicated they were both White/Caucasian and Asian were classified as Asian.

f Other Master’s degrees included students in the Master of Health Services Administration and Master of Health Informatics degree programmes.

g Students from ‘other’ academic departments, including those in multiple departments and in the online MPH program, and those in the undergraduate programme were excluded from the bivariate analyses for academic department.

h Post hoc Tukey’s tests show a significant difference in BAOP scores among students in the undergraduate public health programme relative to those pursuing an MS or ‘other’ Master’s degree; no other significant differences between groups were observed.

i Post hoc Tukey’s tests show significant differences in BAOP scores among students studying Epidemiology, Health Management and Policy, and Biostatistics relative to those studying Health Behavior and Health Education; no other significant differences between groups were observed.

We observed significant differences in beliefs about the controllability of obesity according to degree programme (P = 0·04) and across academic departments (P < 0·001), with post hoc tests revealing a stronger belief that obesity is not within the control of the individual among students in the undergraduate public health programme (relative to those pursuing a MS or ‘other’ Master’s degree) and students studying Health Behavior and Health Education (relative to those studying Epidemiology, Health Management and Policy and Biostatistics). There were no significant differences in weight bias internalisation across programme or department.

Discussion

Among public health trainees, we observed differences in beliefs about the controllability of obesity according to gender, degree programme and academic department. Higher weight bias internalisation was seen among students who identified as female, those who perceived themselves to have a high weight status and those who were food insecure.

Findings from the present study should be considered relative to the literature documenting weight bias among other healthcare trainees and the general population. Mean BAOP scores in our sample of public health trainees (22·9) indicated a stronger belief that obesity is driven by genetic/environmental causes, as opposed to a lack of personal control, relative to a study of student nurses (17·4) in Turkey(Reference Yılmaz and Yabancı Ayhan10), a Mexican study of psychology (18·6) and medical (16·6) students(Reference Soto, Armendariz-Anguiano and Bacardí-Gascón11) and a study of nursing students (17·2) at a US university(Reference Darling and Atav12). Scores were similar to those seen among social work students (23·9) in the same US-based study(Reference Darling and Atav12). This finding may reflect qualities of students who choose to study public health v. other health-related careers, such as a natural orientation towards population level v. individual approaches to health promotion. Public health students also appear to be more likely to recognise genetic/environmental drivers of obesity than the general population. The original reliability study of the BAOP reported mean scores of 16·7 and 14·8 among undergraduate and graduate students, respectively(Reference Allison, Basile and Yuker7), and a general sample of college-aged students in the United Kingdom reported a mean BAOP score of 14·2(Reference Flint, Hudson and Lavallee13). WBIS-M scores in our sample were similar to those reported in a large study of undergraduate university students from Australia, in which students with higher body weights and female students were particularly vulnerable to weight bias internalisation(Reference O’Brien, Latner and Puhl14). The observed relationship between perceived weight status and internalisation of weight bias is consistent with past literature documenting that weight perception is related to susceptibility to weight bias(Reference Lin, Latner and Fung15,Reference Major, Hunger and Bunyan16) and related outcomes such as disordered eating(Reference Isomaa, Isomaa and Marttunen17–Reference Hazzard, Hahn and Sonneville19). Our observation that students at risk for food insecurity had higher WBIS-M scores aligns with a previous study where food insecurity was associated with greater weight self-stigma among adult food bank clients(Reference Becker, Middlemass and Taylor20). Because only public health trainees were recruited for this study, we were unable to directly compare beliefs of public health trainees with the general population. This limitation should be addressed in future studies.

This study was conducted among public health trainees at a single university and, as participation was voluntary, was susceptible to response bias. While these limitations impact the generalisability of our findings, this study is the first of its kind to examine weight bias among public health trainees and provides a foundation for future work examining approaches to address weight bias within public health training and practice. Findings from this study suggest that public health trainees may be more attuned to the complexities of weight relative to trainees in other health-related fields, but are still susceptible to internalisation of harmful weight-biased beliefs.

Overall, there is limited evidence for effective approaches to reduce weight bias, in part due to the paucity of research efforts in this area(Reference Daníelsdóttir, O’Brien and Ciao21), highlighting the need for the development and rigorous testing of intervention strategies that target public health trainees. Significant improvement in explicit attitudes and beliefs towards people with obesity was seen in a study of trainee healthcare professionals who viewed brief, educational films that used a range of strategies to promote stigma reduction (e.g. attributions of weight controllability, empathy induction and debunking weight-based stereotypes)(Reference Swift, Tischler and Markham22). Another recent study conducted among medical students showed that favourable interactions with higher-weight patients were significantly associated with less negative attitudes towards them(Reference Meadows, Higgs and Burke23). These studies underscore the importance of using a range of strategies to address issues of weight bias among public health trainees. Course offerings or school-wide initiatives that raise awareness of size diversity or weight-inclusive health promotion, particularly those that centre individuals with lived experience, could be leveraged to reduce the internalisation of weight bias among the most vulnerable students (e.g. those with higher body weights). To help prepare the next generation of practitioners and scholars to effectively work with individuals with higher body weights, content on the multi-factorial aetiology of weight and on the harms of weight bias could be incorporated into foundational public health coursework.

Acknowledgements

Acknowledgements: The authors wish to thank the Diversity, Equity, and Inclusion Committee in the Department of Nutritional Sciences for their support and valuable input. Financial support: The authors have no financial relationships relevant to this article to disclose. Conflict of interest: The authors have no conflicts of interest to disclose. Authorship: K.R.S. oversaw the study; K.L.R./N.J.L./C.W.L. contributed to the design of the study; K.L.R. oversaw data collection; H.M.W. led data analyses; K.R.S./K.L.R. led the writing of the manuscript; N.J.L./M.R.B./H.M.W./C.W.L. contributed to the interpretation of the results and provided critical feedback on the manuscript. Ethics of human subject participation: This study was conducted according to the guidelines laid down in the Declaration of Helsinki. The study was deemed exempt by the University of Michigan Institutional Review Board.

References

Alimoradi, Z, Golbonia, F, Griffiths, MD et al. (2020) Weight-related stigma and psychological distress: a systematic review and meta-analysis. Clin Nutr 39, 2001–2013.CrossRefGoogle ScholarPubMed
Emmer, C, Bosnjak, M & Mata, J (2020) The association between weight stigma and mental health: a meta-analysis. Obes Rev 21, e12935.CrossRefGoogle ScholarPubMed
Puhl, RM & Heuer, CA (2010) Obesity stigma: important considerations for public health. Am J Public Health 100, 1019–1028.CrossRefGoogle ScholarPubMed
Hunger, JM, Major, B, Blodorn, A et al. (2015) Weighed down by stigma: how weight-based social identity threat contributes to weight gain and poor health. Soc Personal Psychol Compass 9, 255–268.CrossRefGoogle ScholarPubMed
O’Hara, L & Gregg, J (2012) Human rights casualties from the “War on Obesity”: why focusing on body weight is inconsistent with a Human Rights Approach to health. Fat Studies 1, 32–46.CrossRefGoogle Scholar
Phelan, SM, Burgess, DJ, Yeazel, MW et al. (2015) Impact of weight bias and stigma on quality of care and outcomes for patients with obesity. Obes Rev 16, 319–326.CrossRefGoogle ScholarPubMed
Allison, DB, Basile, VC & Yuker, HE (1991) The measurement of attitudes toward and beliefs about obese persons. Int J Eat Disord 10, 599–607.Google Scholar
Pearl, RL & Puhl, RM (2014) Measuring internalized weight attitudes across body weight categories: validation of the Modified Weight Bias Internalization Scale. Body Image 11, 89–92.CrossRefGoogle ScholarPubMed
Gundersen, C, Engelhard, EE, Crumbaugh, AS et al. (2017) Brief assessment of food insecurity accurately identifies high-risk US adults. Public Health Nutr 20, 1367–1371.CrossRefGoogle ScholarPubMed
Yılmaz, H & Yabancı Ayhan, N (2019) Is there prejudice against obese persons among health professionals? A sample of student nurses and registered nurses. Perspect Psychiatr Care 55, 262–268.CrossRefGoogle ScholarPubMed
Soto, L, Armendariz-Anguiano, AL, Bacardí-Gascón, M et al. (2014) Beliefs, attitudes and phobias among Mexican medical and psychology students towards people with obesity. Nutr Hosp 30, 37–41.Google ScholarPubMed
Darling, R & Atav, AS (2019) Attitudes toward obese people: a comparative study of nursing, education, and social work students. J Prof Nursing 35, 138–146.CrossRefGoogle ScholarPubMed
Flint, SW, Hudson, J & Lavallee, D (2015) UK adults’ implicit and explicit attitudes towards obesity: a cross-sectional study. BMC Obesity 2, 31.CrossRefGoogle ScholarPubMed
O’Brien, KS, Latner, JD, Puhl, RM et al. (2016) The relationship between weight stigma and eating behavior is explained by weight bias internalization and psychological distress. Appetite 102, 70–76.CrossRefGoogle ScholarPubMed
Lin, YC, Latner, JD, Fung, XCC et al. (2018) Poor health and experiences of being bullied in adolescents: self-perceived overweight and frustration with appearance matter. Obesity 26, 397–404.CrossRefGoogle ScholarPubMed
Major, B, Hunger, JM, Bunyan, DP et al. (2014) The ironic effects of weight stigma. J Exp Social Psychol 51, 74–80.CrossRefGoogle Scholar
Isomaa, R, Isomaa, AL, Marttunen, M et al. (2011) Longitudinal concomitants of incorrect weight perception in female and male adolescents. Body Image 8, 58–63.CrossRefGoogle ScholarPubMed
Sonneville, KR, Thurston, IB, Milliren, CE et al. (2016) Weight misperception among young adults with overweight/obesity associated with disordered eating behaviors. Int J Eat Disord 49, 937–946.CrossRefGoogle ScholarPubMed
Hazzard, VM, Hahn, SL & Sonneville, KR (2017) Weight misperception and disordered weight control behaviors among US high school students with overweight and obesity: associations and trends, 1999–2013. Eat Behav 26, 189–195.CrossRefGoogle Scholar
Becker, CB, Middlemass, K, Taylor, B et al. (2017) Food insecurity and eating disorder pathology. Int J Eat Disord 50, 1031–1040.CrossRefGoogle ScholarPubMed
Daníelsdóttir, S, O’Brien, KS & Ciao, A (2010) Anti-fat prejudice reduction: a review of published studies. Obes Facts 3, 47–58.CrossRefGoogle ScholarPubMed
Swift, JA, Tischler, V, Markham, S et al. (2013) Are anti-stigma films a useful strategy for reducing weight bias among trainee healthcare professionals? results of a pilot randomized control trial. Obes Facts 6, 91–102.CrossRefGoogle ScholarPubMed
Meadows, A, Higgs, S, Burke, SE et al. (2017) Social dominance orientation, dispositional empathy, and need for cognitive closure moderate the impact of empathy-skills training, but not patient contact, on medical students’ negative attitudes toward higher-weight patients. Front Psychol 8, 504–504.CrossRefGoogle Scholar
Figure 0

Table 1Sample characteristics and bivariate associations with controllability of obesity and weight bias internalisation (n 322)