Background: Most people do not realize how prejudicially damaging they behave, particularly towards the obese. Their discrimination has bean deemed, unconsciously perhaps, so acceptable by society.
Methods: This paper describes a high school seniors exploration of prejudice and discrimination towards the obese.
Results: Through interviews with bariatric surgeons, bariatric patients, an obese victim of prejudice in her high school, attendance at support group meetings, statements from others experiencing similar bias in their workplace as well as a review of the relevant literature, the author developed a new understanding of the extent and depth of prejudice against the obese in North American society. She realized how this prejudice limits social opportunities and access of all sorts, interferes with employment opportunities, and even how deeply it penetrates the medical community.
Conclusion: The intent of this paper is to educate those in society who continue to discriminate against the obese, and to open our eyes to our own behavior, as the authors have been opened.
Key words: Prejudice, discrimination, morbid obesity, bariatric surgery.
For an obese woman living in todays society, life can be made very hard. Seemingly simple tasks such as buckling a safety-belt, sitting in a chair, grocery shopping or standing in line are painful both physically and, even more so, psychologically. The obese are constantly ridiculed and prejudged as to their lifestyles, eating habits and personalities. For Leslie Lampert, a normal weight woman who spent 1 week in a fat suit, the changes in peoples behavior towards her were astounding.
The preconceived notions that the majority of normal weight people have toward the obese are mistaken. The image that enters most of our minds when envisioning a fat person would most likely be an overweight woman, struggling down the street. Perhaps she is eating a donut. You probably think she smells bad. You pity her, you ridicule her for not being able to control her eating. You may even feel that she is a slob, lazy, stupid, and it is her fault she weighs so much; she should go on a diet. You are probably convinced that she has no will-power, and she represents your deepest fears of getting fat and not being to control yourself with eating. You might make fun of her, snickering behind her back as passes by, just loud enough for her to hear. Once she is out of earshot, you stop your snickering, feeling some sort of power over her, like you are suddenly better than she is. Or maybe for just moment you show some humanity and wonder why you did what you just did ... did she really deserve that?
Fat people are not lazy, stupid, or uncaring anymore than a normal weight person is. They have just as much willpower, more in some cases. In a personal letter sent to Dr. Latham Flanagan of the Oregon Center for Bariatric Surgery, the woman wrote, "A client once told me, Its easy to lose weight; just quit eating. Even though I quit smoking after 30 years, people assume I have no willpower." Most of these fat people are some of the kindest, most caring people I have ever met. They understand humiliation, pain, isolation, and the absolute cruelty of the human race, because they live with these phenomena every day of their lives.
What Is Obesity?
Obesity, defined as 20% over ideal body weight, is believed to affect as many as 30% of Americans, or over 75 000 000 people! Severe clinical obesity, or morbid obesity, defined as 75% over ideal body weight (45 kg or 90-100 lb excess weight for an average adult) is believed to affect over 5% of Americans, or about 12 000 000 people. The numbers are not entirely accurate because many severely obese people hide from conventional sources of these statistics. Their reasons include fear of embarrassment or severe physical disability.
The cause of severe obesity has been, and continues to be, highly misunderstood. Traditionally, obesity has been considered to be a psychological or a social diseasea disease of sin and sloth. The obese person has been considered to be not quite normal, and often the sideshow freak of a traveling circus. In the last two decades, there have been extensive studies into the cause of obesity and the nature of obese persons. Medical science now understands morbid obesity to be primarily a genetic disease, an organic disease of abnormal fat metabolism. The mechanism, as experienced by the morbidly obese person, appears to be that an amount of food sufficient in calories to meet basal metabolic needs and energy expenditure of the muscles is not experienced as being satisfying. To feel satisfied, as any normal weight person would feel after a meal, the obese person must eat more than he/she requires.
But Are They Normal?
The severely obese suffer for something that they have little control over, as it largely a genetically determined metabolic disease of abnormal fat storage.2 A study completed in 1985 by Dr Stunkard and his Danish colleagues of 3580 adoptees found a strong correlation in weight between the biologic parents, but none with the adoptive parents. This is considered to be the definitive proof of the genetic origin of severe obesity.
An obese person is as normal, psychologically, as anyone else. "The long-standing belief that obese persons suffer disproportionately from emotional disturbances has been shown to be incorrect. In two of (Moore and colleagues) studies obese persons actually had lower levels of psychopathology than their non-obese counterparts (in a study of 1660 people in midtown Manhattan)."3
Further, medical science has been able to demonstrate that morbidly obese persons are psychologically normal in all respects except for some traits that are caused by social prejudices. "Emotional problems specific to obese persons do exist, but they are now seen as consequences of the prejudice and discrimination directed against obese persons."3 Therefore, the seriously obese are mentally as normal as lean individuals and, where they behave otherwise, it is either a normal human response to prejudicial treatment or a reflection of a similar incidence of mental disorders which are experienced by the non-obese population. Their large size and related diseases are a manifestation, phenotype, of their genetic inheritance which all humanity is heir to.
The Beginnings of Prejudice
If a child is not told that it is wrong to discriminate, they will carry it into their adult lives, thinking that it is acceptable. From religious bigotry to ethnic hatred, racism to sexism, bigotry has been ingrained through generations of accepted hatred, and it is no different for sizism. The idle comments made by children are allowed to slip by, sometimes are even reinforced, and continue on into adulthood.
Unfortunately, it seems that societal acceptance of prejudice toward the severely obese has already occurred across the globe, and steps to rectify the situation are slow at best. The barriers to break down have been made strong through the years of letting this prejudice slip by the wayside unnoticed. The media, from MTV to the local newspaper, contributes to the stereotype of the skinny American woman. Over the last 30 years, as the weight of the average American woman has steadily increased, the models used by Playboy magazine have grown progressively thinner.5
But perhaps this discrimination is more deep-seated than it initially appears to be. "To many, obesity symbolizes an inability to control oneself or to maintain personal health."1 In a society where control over oneself is so important to the individual, it is no wonder the obese are picked on so readily. They represent that part of all of us that we assume to be so dangerouslack of self-control. Let us analyse a not atypical example of the types of treatment the obese often receive.
Pamela (not her actual name) attended a Eugene high school between the fall of 1991 and the fall of 1992, her freshman and half of her sophomore years. At 155 cm (5'2") and 180 kg (395 lb), each day of school met with constant harassment and threat of personal injury. She recalls being pushed down stairs, her hair being pulled out, being spat on, and of having numerous objects thrown at her. She would find pig snouts taped to her locker, jokes about her weight shouted out, such as "go to Jenny Craig/Weight Watchers," and "shes so fat she cant fit through the front doors." She became the school joke. On Valentines Day, students put up posters stating "if youre fat and ugly like Pamela, you need Valentines Day Dating Service."
On an extreme occasion, three boys followed her home from school and maced her; she had in no way provoked them. The boys were arrested, but released on bail. The following day she did go to school, where the boys were waiting for her at her locker. She went directly to the office where she called her mother to come pick her up. Pamela was dismissed from school for 3 months on the grounds that she had disrupted the learning processes of other students.
She attempted to talk with the administration and with school counselors. The principal told her to "deal with it" and that it was "her fault" and she should "go on a diet". When she was harassed in the hallways, Pamela says that "the teachers would just stand and watch".
Pamela began to skip school; she could not bear the thought of going and having to face the constant ridicule. Finally in late fall of 1992, she dropped out and began attending school at the Opportunity Center, a remedial high school. Conditions were much better there. She says that the teachers would not allow the harassment, and she was never made fun of or beaten up.
In 1993, Pamela had the gastric bypass surgery. Following this, and with her subsequent weight loss, Pamela noticed significant improvement in the way she was treated, and in the way she felt about herself. When returning to her previous high school to pick up her yearbook, those who had known her could hardly believe she was the same person. She then weighed 113.5 kg (250 lb) and remembers looks of admiration. She was in no way harassed.
She is now at 79.5 kg (175 lb) and beautiful. She is actively dating, has a good job and many friends.
Social Disadvantages of the Severely Obese
As a normal weight person 177.5 cm, 65.9 kg (5'11", 145 1b), I never think twice about using a public bathroom, going out to eat, flying, riding a bus, grocery shopping, sitting in class, buying clothes, applying for a job, or any number of daily activities. However, for an obese person, each of these tasks is a struggle. Personal hygiene is extremely difficult; when eating in public, everyone around the obese seems to become an expert in their diet, and often express an opinion. Some people check the contents of a grocery cart and make comments.7 The desks are not big enough in the classroom, the seats are not big enough in airplanes, no one will sit next to them on the bus, and special stores are needed for buying clothes. When recently attending a support group for bariatric surgery patients, one lady commented that she could not remember the last lime she had shopped in Meier & Frank, and was ecstatic for just having done so. Many employers will not even consider hiring an obese person; and if they do, the fat person is kept out of sight. Everyday is a trial, filled with isolation.8
When you are obese, no one wants to talk to you, no one wants to have you around because you are an embarrassment; of course no normal weight person would ever stop to consider how much embarrassment an obese person feels daily. Even family members ostracize you.
America is a society that would like to think of itself as open-minded and liberal. However, I know of no one who is not guilty of ridiculing a person at least once for being fat. Everyone is guilty of it, and yet nothing is done about it. Racism, religious prejudice, sexual discrimination, class prejudice, these are all things that we hear and read about daily. These societal problems are topics for lunch-time or coffee-house talks, essays and articles. So where does this kind of bigotry fall in? Weight prejudice? Sizism?
This sizism is the last place where people can discriminate openly without fear of reprimand. Were the last safe prejudice ... The fat person is the last person you can safely kick around."10 "Fat people (report) that they are accosted on the street by strangers who admonish them to lose weight. Often their own children are ashamed of them ... even many doctors find fat people disgusting, and some refuse to treat them."11
Prejudice in the Medical Community
It is not only high school students who behave in a prejudicial manner towards the obese. Young children can be brutally honest in their comments (e.g. "Mommy, look at the fat person!"). Adults are just as bad, but they are better at hiding their prejudice. Even doctors can be ignorant and cruel. In the obesity surgery patients support group, one lady remembered asking her family doctor if he had any advice on how best to lose weight; she says he stood back from her and replied "have you ever seen a fat person in a concentration camp?" Another woman reported that after having back surgery, her doctor had complained to her of having to cut through the two inches of blubber.
Many family and general practitioners do not even know of the existence of obesity surgery, or doubt its reasonability.
Much of this type of anti-fat sentiment derives from the physician trainers who place such an emphasis on the need for an obese person to lose the weight. Physicians see obesity as a self-inflicted problem, for which, if the individual would only stick to a diet, they could cure themselves.12 "... the majority of surgeons I know do not seem to seek to understand or even tolerate the obese and their problems." Coming from another surgeon, Dr George S.M. Cowan, a Professor of Surgery at the University of Tennessee at Memphis, this statement is particularly powerful.
Along with the psychological impact of such a disease, there are also significant medical health issues. Hypertension, strokes, heart failure, heart attacks, diabetes, cirrhosis of the liver, accident proneness, operative risks, osteoarthritis, gall bladder disease, sleep apnea, heartburn, urinary stress incontinence in women, benign brain swelling, cancer of the uterus, breast and ovaries in women, cancer of the prostate in men, cancer of the colon, and an increase of sudden death risk from unknown causes.13
Men aged 15-69 years, and who are 20% over ideal body weight, experience mortality rate increases of 30%. Excess mortality rate increases by 15% for cancer, 60% for stroke, 80% for nephritis, and 140% for diabetes.13 Although these figures are 17 years old, instances of obesity are on the rise in America, making the figures even more significant than they appear.
Unfortunately, many insurance companies do not cover the Gastric Bypass or Gastroplasty because they are seen as cosmetic surgeries, although, once surgery is completed, the patient is left with a scar from xyphoid to umbilicus. Also, once weight loss begins, the individual will develop large flaps of skin under the upper arms, inner-thighs, neck and a large apron of abdominal skin that may extend down to the thighs and even knees. Thus, despite some insurers claims that the gastric bypass and other related surgeries are cosmetic, it is quite the contrary; "if anything, it (bariatric surgery) is clearly anti-cosmetic rather than enhancing the formerly-obese persons appearance."14
After surgery is performed on the obese individual, and subsequent weight loss occurs, most of the health issues associated with obesity, the co-morbidities, either disappear or are drastically reduced. The individual is more inclined to seek advancement, additional education, get off the welfare rolls and acquire a job (self-image has improved, and employers are more likely to hire a thinner person over the obese). The individual is able to sleep at night, fit into chairs, drive, move without constant physical discomfort, and has a mental outlook that is much brighter due to the fact that the constant ridicule is no longer tangible. Their self-confidence soars, and with the common case of employment, so do their bank accounts. They are no longer a burden on society, for they no longer live off Welfare. Society actually reaps a double benefit from the successful treatment of the formerly obese: (1) no more medical or entitlement support costs; (2) they now pay taxes. To understand even more of the implications of this disease, we will take a closer look at the costs of serious obesity before treatment.
To the Individual
The costs to the individual are often enormous. The hundreds of different diets the obese person will try add up, and will be effective for only a short time until the weight returns. Medical costs for doctor bills, depression/sleeping pills, unemployment, and special clothing are all costs the obese person has to endure. Sleep apnea, a common problem, results in the individual falling asleep on the job, which usually concludes in their being fired.
As to obtaining a job initially, "employers usually consider the morbidly obese poor candidates because of their unfavorable appearance, their inability to fit into office furniture or into factory environments, and their high absenteeism due to illness."9 Often a less qualified, but thinner applicant will be hired over an obese person.
Jane (not her actual name) graduated in the top 10% of her class from the Colorado Institute of Art and is highly skilled in various computer applications. She did not realize how wide-spread sizism is until she and three cousins applied for a job together. "I knew I was qualified for a position and expected to be interviewed." Katy was also qualified for a position and had good references. Jenny and Pat had been "drawing public assistance" for several years.
Jane went home in a fury, called up the potential employer and demanded an interview, "but they had no record of our applications."
Allan Cox surveyed more than 1000 middle and top managers about how 105 qualities and characteristics would affect executive success at their companies. More than 24% said even 15 lb (6.8 kg) of excess weight would have a somewhat negative effect, and 4% said that the effect would be very negative. Up the ante to 50 lb (22.7 kg) excess weight and 43% thought the effect would be somewhat negative, while 27% said it would be very negative.15 "Employers feel they dont have to give you good raises, because youll have a hard time getting a job elsewhere."15
Stunkard reports that "twice as many obese women (22%) were downwardly socially mobile as were upwardly socially mobile (12%)." Also, overweight women are 20% less likely to be married,16 and felt inadequate in their parental roles (due in fact to the embarrassment of their children and other family members). For obese high school students, acceptance rates into college are lower, despite qualifications, high school performance or application rates.4
The average obese women has 4 months less schooling than a non-obese woman, and is 10% more apt to live in poverty.4 Whether the inclination towards poverty is a direct result of the lesser schooling, or from the social pressures and physical inabilities, has not been clearly defined. I am more prone, however, to believe the latter from my experience. Social pressures and prejudices can be so overwhelming as to push the obese individual out of public schooling, as in the case of Pamela. Taking into consideration that obesity is largely genetic, the parents are more likely to be obese themselves, possibly on welfare, and not able to afford alternative education. The child would most likely not attend college, most likely fall into the welfare program, or work menial jobs on low pay, and therefore be at or below the poverty-line. Beyond the individual, what does this mean to our society?
Obesity not only costs the individual but also society as a whole.
The amount of money that is poured into weight-loss programs each year is incredible. "Americans spend over $33 billion a year to lose weight, most regain it quickly ..."18 Severe obesity cannot be treated effectively with dieting, because the weight simply returns. The National Institutes of Health Technology Assessment Conference of 1992 Voluntary Methods for Weight Loss and Control determined that in the best of available weight-loss programs using any combination of diet, behavior modification, exercise, or medication, two-thirds of any weight lost is regained in the first year after the program, and almost all within 5 years. Surgery is the only effective treatment.
Surgical Treatment of Severe Obesity
Surgery has often been considered a desperate last resort for treating severe obesity. However, results of current operative procedures in the last 15 years have improved to the point that the National Bariatric Surgery Registry reports a 0.3% mortality rate in over 15 000 patients.19
Lifestyles of the severely obese are quite altered following surgery. In a study by Rand and Macgregor, 57 consecutive patients who received obesity surgery reported drastic reductions in the amount of perceived prejudice connected with their weight.20,21 "Preoperatively, 40% ... of patients answered always or usually to every item describing acts of prejudice or discrimination ... (postoperatively) no patient reported the same degree of prejudice and discrimination ..."
For severely obese individuals, surgical treatment is the most effective way to treat their disease, both physical and societal, if they are willing and able to have a major operation. For those who cannot undergo surgery or who do not qualify, there is as of yet no answer to their problem.
Ignorance is the driving force of prejudice and discrimination. Until society is awakened to the unjust treatment of the obese, the discrimination will continue. Just as racism, sexism and other prejudices have been out in the open and recognized by the majority as wrong, so must sizism. As ignorance is the cause, enlightenment through education is the cure. Organizations, such as the National Association to Aid Fat Americans, or NAAFA, have already begun the process of stopping the discrimination towards the obese in the work place, but it is a slow process. Individuals must be educated, laws enacted, and cultural norms changed so that the protective bastions which allow the devastatingly harmful prejudices against the obese cease to exist.
Obesity does not arise from lack of self-control. It is largely a genetic disease which contributes to severe physical health problems, as well as psychological distress from social pressures, and a lower socioeconomic status due in great part to prejudice. Obesity is a disease which afflicts one-third of all Americans, and is on the rise. Obesity will not go away; it is a growing epidemic in our society which needs to be recognized and effectively dealt with.
1. Lampert L. Fat like me. Ladies Home Journal May 1993: 154-215.
2. Stunkard AJ, Sorenson TIA, Harris C, et al. An adoption study of human obesity. N Engl J Med 1986; 314: 193-8.
3. Stunkard AJ, Wadden TA. Psychological aspects of human obesity. Human Obesity: General Aspects 1992: 352-8.
4. Wadden TA, Stunkard AJ. Social and Psychological Consequences of Obesity. Ann Intern Med 1985; 103: 1062-7.
5. Presentation to the American Society for Bariatric Surgery. New Orleans June 1991.
6. Interview of Pamela. 19 October 1995.
7. Anonymous. Personal letter.
8. Various Speakers. Oregon Center support group for Bariatric Surgery Patients, 15 October 1995.
9. Pories WJ. The surgical approach to morbid obesity. Textbook of Surgery. Philadelphia: W.B. Saunders 1991: 851-65.
10. Lampert W. Obese Workers Win On-the-Job Protection Against Bias. Wall Street Journal, 12 November 1993: B1+.
11. Kolata G. Are fat people last to beat bias? Eugene Register Gaurd. 23 November 1992: A1+.
12. Robinson BE, Gjerdingen DK, et al. Obesity: A move from traditional to more patient-orientated management. JABFP 1995; 8(2): 99-108.
13. Yudkin J. Nutritional, psychological and social aspects of obesity. Ruschlikon-Zurich: Somogyi, JC 1978: 146-50.
14. Cowan GSM Jr. Personal letter.
15. Zetlin M. Sizable problems. Savvy Manager, August 1988: 22-4.
16. Associated Press. Obese women suffer more than men. Eugene Register Gaurd, September 1993: A3.
17. Serdula M. Weight control practices in U.S. adolescents and adults: youth risk behavior survey and behavioral risk factor surveillance system. National Institutes of Health Technology Assessment Conference. Methods for voluntary weight loss and control. Bethesda, Maryland. March 30-April 1, 1992.
18. Associated Press. Experts urge disclosure in diet programs. Eugene Register Gaurd, 6 December 1994: A6.
19. National Bariatric Surgery Registry pooled report. Iowa City 52242-1086, USA.
20. Rand CSW, Macgregor AMC. Morbidity obese patients perceptions of social discrimination before and after surgery for obesity. South Med J 1990; 83: 1390-5.
21. Rand CSW, Macgregor AMC. Successful weight loss following obesity surgery and the perceived liability of morbid obesity. Int J Obes 1991; 15: 577-9.
Ms Sahale Flanagan began this paper in her junior year in 1994, as a senior research project for the International High School of South Eugene. It was her intent to focus on the social, economic and psychological effects of obesity. As she talked to recipients of the gastric bypass and other related surgery, her eyes were opened to the deep-seated prejudice and discrimination towards the obese in our society. She conversed with the support group for bariatric surgery patients and those considering the surgery, interviewed a young woman who had experienced severe discrimination in her high school, obtained several personal letters of firsthand accounts of prejudice in the workplace as well as everyday lives, and accessed the University of Oregon Knight Library and Sacred Heart Hospitals medical library. Thus, as the research progressed, she became involved with the more human side of obesity. Ms Flanagan noted that the media supports the slim female, as does fashion, furniture, and society. She found that the severely obese are perceived by others to be disgusting, almost not fit to be called humans.
In the above paper, awarded an A by the evaluating committee, Ms Flanagan has attempted to bring to light one of the last bastions of discrimination that has been deemed, unconsciously perhaps, as acceptable to society.
Mervyn Deitel, MD