OBJECTIVES: To examine health professionals' views of overweight people, to compare these to their views of smokers, and to explore the role of level of severity on these perceptions.
DESIGN: A postal survey of health professionals employing a two by two, independent factorial design. The health category (overweight or smoker) was divided by level of severity (moderate or extreme), so that respondents received questionnaires about either: (i) moderately overweight people; (ii) extremely overweight people; (iii) moderate smokers; or (iv) heavy smokers.
PARTICIPANTS: Two-hundred and fifty-five general medical practitioners and clinical psychologists in the north of England.
MEASUREMENTS: A questionnaire was designed to explore beliefs about the causes, attitudes towards, and perceptions of responsibility of overweight people and smokers.
RESULTS: Moderately and extremely overweight people were perceived as having reduced self-esteem, sexual attractiveness and health, and to be moderately responsible for changing their situation (but less so than smokers). There were clear level effects in the perceptions of overweight, but not so for smokers. Of the four groups, moderately overweight people were viewed most positively and extremely overweight (obese) people were viewed least positively.
CONCLUSIONS: Overall, health professionals' attitudes to overweight people were neutral to negative rather than entirely negative. However, where apparent negative attitudes were more likely to be directed at obese people than moderately overweight people. As obesity is a risk to health, the practice implications of health professionals' negative attitudes or patients' reticence to visit professionals who treat them with disregard must be addressed.
A number of investigators have reported that health professionals hold negative views of overweight and obese people. Negative attitudes have been observed in medical students and qualified practitioners,1,2,3,4 nurses,5,6 dietetic students and dietitians,7 and mental health professionals.8 Negative attitudes towards overweight people may be linked to beliefs about the causes of weight gain. In particular, the belief that weight is under volitional control is associated with more negative attitudes and a perception of personal responsibility and blame.9 If people assume overweight is the overweight person's fault, then denigration and stigmatisation are more likely.10 Thus, overweight people are blamed for their fate because they are seen as the cause of it. Likewise, popular perception seems to have it that overweight is due to such things as psychological or personality defects. Such beliefs pervade despite the fact that most formal analyses do not support the proposition.11,12
Given the apparent widespread and overt negativity towards overweight people in industrialised countries, negative views amongst health care providers should hardly be surprising. They are a concern, however, because health professionals have a particular role in providing care for the overweight and obese, a role that may be compromised by prejudicial attitudes. Several commentators have suggested that negative attitudes towards this patient group, or indeed beliefs about the usefulness of intervention, may be a barrier to good practice.4,13,14,15 Treating obesity is difficult, if success is judged in terms of long-term, sustained weight loss. Nevertheless, recent evidence summarising the effectiveness of different treatments has provided new opportunities for improved patient care.16,17 Such opportunities may be squandered if health professionals' negative perceptions of overweight patients and treatment efficacy are allowed to get in the way of good practice.
However, the evidence for widespread negativity amongst professionals is not clear-cut, and it is difficult to draw strong conclusions about the intensity or prevalence of such perceptions. For example, some studies have reported neutral, mixed or positive attitudes.18,19,20,21 These types of studies have been criticised on methodological grounds.21,22,23,24 A further problem in this research area is the failure to include an appropriate comparison, making it difficult to draw conclusions about perceptions relative to other patient groups or conditions. Another neglected issue is the degree of overweight. Those most overweight or obese are at greater risk of health problems,25 and so in greatest need of intervention. It should be expected that negativity would increase with increasing overweight because this is more deviant from the norm.8 Thus, it may be that the very people who are most in need of help are the ones for whom prejudicial attitudes are most likely to get in the way.
The present study therefore aimed to explore the attitudes and beliefs of UK health providers towards overweight and obese people. These were compared to health professionals' views of smokers. Smokers were chosen as the comparison group since patients who smoke are frequently encountered by health professionals, and smoking is a widespread habit with major implications for public health. Smoking, like overweight, is maintained by a variety of psychological, social and biological factors, although the concept of addiction is more generally applied to smoking than to overweight. In addition, encouraging smokers to stop smoking and stay abstinent represents a challenge for health professionals akin to aiding overweight patients to maintain weight loss. Accordingly, it was hypothesised that health professionals would attribute a variety of causes to overweight and obesity, but that they would place greater emphasis on factors within the control or responsibility of the individual than for smokers. Second, they would hold overweight people as more personally responsible for their situation than smokers. Third, personal responsibility and would increase according to the level of severity. Fourth, negative attitudes would increase according to the level of severity. Finally, the most negative attitudes would be directed at obesity.
A postal survey of 764 health professionals was undertaken in two health districts in the north of England (Leeds and Bradford). All 670 general medical practitioners (GPs) and 94 clinical psychologists (CPs) registered in these districts were sent questionnaires. GPs were identified from lists obtained from Leeds and Bradford Family Health Services Authorities, and CPs from the Northern and Yorkshire Regional Health Authority's register.
The survey employed a two by two, independent, factorial design (health category by level of severity), so that respondents were allocated to receive one of four questionnaires about either: (i) moderately overweight people; (ii) extremely overweight people; (iii) moderate smokers; or (iv) heavy smokers.
Four corresponding versions of the questionnaire were developed, incorporating sections on (i) the demographic details of respondents, (ii) beliefs about the causes of overweight or smoking, (iii) attitudes towards the overweight person or smoker, and (iv) perceptions of responsibility of the overweight person or smoker. A template of the questionnaire can be obtained from the first author.
Beliefs about the causes of overweight.
The items for this section of the questionnaire incorporated those from Bray et al's26 survey of causative factors of obesity and Allison et al's24 Beliefs About Obese Persons (BAOP) scale. Additional items included areas not addressed by these two scales. As far as possible, the same questions were used to explore beliefs about overweight and smoking (eg emotion-related and demographic factors, genetics, and lack of willpower). However, for the questionnaires on smoking, some obesity items were replaced by smoking-relevant items (eg advertising, lack of other meaningful activities, repeated attempts at quitting).
Attitudes towards the overweight person.
This section was developed using Allison et al's24 Attitudes Towards Obese Persons (ATOP) scale. The ATOP consists of 20 items covering a range of issues including attractiveness, perceived self-esteem and social inclusion. Whereas Allison et al originally used the term ‘obese people’, in the present study this was changed to ‘moderately overweight people’ or ‘extremely overweight people’, as required. The same attitude items were used in the questionnaires on smoking, with the terms ‘moderate smokers’ and ‘heavy smokers’ replacing ‘moderately overweight people’ and ‘extremely overweight people’.
Perceptions of responsibility of the overweight person.
Despite references to the role of perceived responsibility in perceptions of overweight people in the attitudes literature, no scale specifically exploring personal responsibility in relation to obesity could be located. Therefore, questions on responsibility were developed by the investigators. These included concepts of general responsibility; responsibility to recognise the existence of a problem, motivate themselves to change, seek help, and be aware of the effect on others; and the legitimisation of pressurising overweight people to change.
For each of the three sections of the questionnaire, a six-point Likert scale was used for respondents to indicate the level of agreement with each statement. (For the beliefs about causes items, 1=not important, 6=extremely important. For the attitudes and responsibility scales, 1=strongly disagree, 6=strongly agree). During scoring, the direction of attitude and responsibility items was noted and all items phrased and scored in a positive direction.
All GPs and CPs were allocated to one of the four groups by alternation, alphabetically according to surname. As some participants were based at the same practice or department, this ensured questionnaire types were not clustered by geographical location. All participants were sent a questionnaire by post, with a covering letter requesting their help, explaining the survey and assuring anonymity. Stamped-addressed envelopes (SAE), an incentive scheme (£20 book token) and two reminder letters were used in an attempt to promote the return of questionnaires.
SPSS for Windows was used to create a database, and for statistical analysis. To test for demographic differences across groups, χ2 tests and one-way analyses of variance were used for categorical and continuous data, respectively. Three-way, independent ANOVAs (respondent profession, health category and level of severity) were undertaken initially to determine whether differences existed between GP and CP responses. Some significant differences were found between the two groups and are noted in the results. However, they were all main effects for profession indicating the pattern of response to be no different for overweight or smoking. Therefore, responses for both groups of professionals were combined in the main analysis.
Thus, two-way, independent ANOVAs (health category by level of severity) were used to test for differences in respondents' views across the four questionnaire categories. In addition, to further explore the role of level of severity for each health category, independent t-tests were used. To take into account the number of tests undertaken, the level of significance was lowered to the 1% level.
Principal components analyses with oblimin rotation were undertaken on the attitude and responsibility scales, as a means of exploring their psychometric properties. This approach can be used to investigate whether the items within a scale may be grouped in a meaningful way to describe a smaller number of underlying principles or ‘latent variables’.27 These procedures were undertaken separately for the overweight and smoking questionnaires. Cronbach's alpha was also computed to assess the degree of internal consistency of the scales.
Two-hundred and fifty-five (33.4%) health professionals participated in the survey. More GPs (n=204) than CPs (n=51) took part, but the response rate was proportionally higher amongst CPs (54.2%) than GPs (30.4%). Respondents in each of the four questionnaire groups had similar characteristics. There were similar numbers of men and women, and an approximate 80:20 split of general practitioners (GPs) to clinical psychologists (CPs) in each group. The mean age of respondents was 40.9 y, and the mean number of years spent in their profession 14.4. Nearly 90% described their ethnic origin as ‘white’, ‘British’ or ‘Caucasian’. In addition, there was no significant difference in response rate to the ‘overweight’ or ‘smoking’ questionnaires.
Respondents to the overweight questionnaires (both levels) were also asked for height and weight data, and for their classification of moderate and extreme overweight. The overall mean for respondents' body mass index was 23.2. Means for the categorisation of moderate and extreme overweight approximated at 20% and 45% above ideal weight, respectively. Independent t-tests revealed no significant differences between these characteristics for respondents of the two levels of questionnaire. Respondents to the two smoking questionnaires were asked questions about their smoking status and for their classification of moderate and heavy smoking. There were similar numbers of smokers, nonsmokers and ex-smokers among respondents to the two questionnaires. The number of smokers at each level was too small to perform meaningful statistical analysis, so a χ2 test of the numbers of non-smokers and ex-smokers was undertaken. No significant differences were found. Respondents to the two levels of questionnaire also had similar perceptions of what constitutes a moderate or heavy smoker. The mean for the categorization of moderate smokers was 9.4 cigarettes per day, while it was 21 cigarettes per day for the heavy smokers. There were no significant differences in these categorisations for the two questionnaire types.
Overweight vs smokers.
Table 1 shows that the most important perceived causes of being overweight or a smoker were quite different: physical inactivity and interpersonal factors, respectively. In addition, depression was seen as an important contributing factor to being overweight, but not for smoking (F[1,251]=25.1, P<0.001). Genetic factors were seen as a reasonably strong factor causing people to become overweight (more so at the moderate level), but viewed as unimportant in causing people to smoke (F[1,251]=217.1, P<0.001). Mood changes were seen as significantly more important factors in causing people to be overweight (F[1,251]=13.5, P<0.001).
Some similarities existed across the groups. For example, while interpersonal factors were rated as the strongest influence on smokers, and significantly more important than for overweight (F[1,251]=37.9, P<0.001), they were also rated highly for causing overweight (either level). Gender was not rated especially highly in any of the groups (although it was rated significantly higher in terms of causing people to be overweight, F[1,251]=12.8, P<0.001). Personality and addiction were ranked highly for smokers and overweight, especially at the extreme level.
GPs were significantly more likely than clinical psychologists to attribute both overweight and smoking to a lack of willpower, genetic factors and personality (smallest F[1,247]=6.75, P<0.01).
Level of severity.
For both levels of overweight, physical inactivity was rated as the most important causative factor. Other similarities across the levels were apparent: addiction, interpersonal factors and depression were all rated relatively highly. Many factors were perceived as somewhat important (personality, external stressors, mood changes, genetic factors, lack of willpower, socio-economic status and repeated dieting). The items viewed as least important for both levels were age, gender, metabolic defects and, least important of all, fat cell defects. The similarity in perceived causes of moderate and extreme overweight is reinforced by finding a significant difference in the mean rating of only one variable, ‘a person's age’ (t=2.84, P=0.005).
The patterns of causative factors were also very similar for smokers across both levels. Interpersonal factors were perceived by respondents as the most important causative influence. External stressors, addiction and personality were ranked as the next most important influences upon smoking. Most other factors were rated as having a moderate impact on the likelihood of someone smoking. Age and gender were rated low, with genetic factors rated the least important causative factor of all, indicating that the health professionals surveyed did not believe in a genetic propensity to smoke. Independent t-tests performed to examine for differences in the perceptions of respondents according to smoking severity (moderate vs heavy) indicated no significant differences.
Overweight vs smokers.
Table 2 shows that, in comparison to smokers, respondents rated overweight people as significantly less happy, less likely to feel they are as good as other people, more self-conscious, more dissatisfied with themselves, less self-confident, and more likely to be ashamed of their condition (smallest F[1,251]=6.84, P<0.01). All these items were given lower scores by respondents, indicating negative attitudes relative to smokers, and neutral to negative on the attitude scale. Taken together, these findings appear to describe a view of the overweight person that can be summarised in terms of reduced self-esteem.
Smokers were rated significantly more negatively for the following items: marriage potential, tidiness, comfort in social contexts, similarity in personality to others, expecting to lead a normal life, and not being one of the worst things that could happen to someone (smallest F[1,251]=10.0, P<0.001). These indicate a different emphasis to that found for responses to the overweight questionnaire, and seem to describe a perception of ‘social difficulties’ among smokers.
These conclusions are supported by the results of the principal components analyses. For the overweight data, three factors were extracted, accounting for 54.0% of the variance: ‘Social difficulties’, ‘Self-esteem’ and ‘Attractiveness/Personal appeal’. The same three factors, accounting for 44.5% of the variance, were found for the smoking attitude data. This suggests that the attitude scales were measuring similar concepts for both health categories. In both cases, factor structures supported the pattern of statistically significant differences found between overweight and smoking attitudes. GP's ratings were significantly lower than those by clinical psychologists on nine of the 20 items (smallest F[1,247]=7.44, P<0.01), these items mostly relating to social difficulties. This difference applied similarly to overweight and smoking.
Level of severity.
Those at the extreme level (for overweight and smoking combined) were found to be significantly less happy than others, feel they were not are as good as others, less likely to be as successful as other workers, have reduced marriage potential, be lacking in self-confidence, anticipated discomfort in social contexts, less sexually attractive, more family problems, and to be one of the worst things that could happen to someone (smallest F[1,251]=8.20, P<0.01). Therefore it is apparent that the level of severity affected the attitudes of respondents, with by far the most negative attitudes towards the extreme level.
Independent t-tests compared the two levels of the overweight health category. Significant differences for level were found for 14 of the 20 items (smallest t=2.77, P<0.01). In all cases the extremely overweight person was viewed more negatively. The differences in the perceptions of moderately and extremely overweight people were not only in terms of perceived esteem, but were more general. Notably, obese people were rated lowest for sexual attractiveness and health.
While overweight people overall were seen as less self-confident than smokers, this was particularly marked at the extreme level, with extremely overweight people seen as the least confident of all (F[1,251]=8.15, P<0.01). In addition, extremely overweight people were viewed as less healthy than moderately overweight people, but moderate smokers were viewed as less healthy than heavy smokers, and the least healthy of all four groups (F[1,251]=25.7, P<0.001). This is an unusual finding in that one would expect heavy smokers to be viewed as less healthy than moderate smokers. While there was a significant level effect for the item on sexual attractiveness, so that those at the extreme/heavy level were perceived as less sexually attractive, extremely overweight people were perceived as the least sexually attractive of the four groups (F[1,251]=9.71, P<0.01).
Mean attitude score.
Cronbach's alpha for the 20 attitude items was calculated as 0.83, thus indicating good internal reliability of the scale and suggesting that the same overall concept was being measured by the items.28 When two-way analysis of variance was performed for the mean attitude score, a significant level effect was found (F[1,251]=29.8, P<0.001), indicating more negative attitudes at the extreme level of the health categories but even then only at the mid-point of the scale. A significant interaction effect was also found (F[1,251]=7.20, P<0.01), with the perception of the moderately overweight being the most positive of all four groups.
Overweight vs smokers.
There were no items for which overweight people were rated significantly more ‘responsible for’ than smokers (Table 3). However, a number of items were rated relatively highly (4 and above) for both the moderate and extreme levels, suggesting that respondents believed overweight people should try to understand what causes them to be overweight, motivate themselves to lose weight, recognise that there is a problem, and recognize that there is a risk to their health. Table 3 also shows that smokers were rated as significantly more responsible than overweight people for most items. The high ratings reveal that respondents believed smokers should be taking action and be subjected to pressures to take action.
Principal components analyses with oblimin rotation undertaken separately on both the ‘overweight’ and ‘smoking’ questionnaires extracted two factors in each case: ‘Responsibility to act’ and ‘Acceptance’. These accounted for 56.0% of the variance for the overweight questionnaires and smoking questionnaires alike. The items loading on the observed factors generally reflected the patterns observed through the tests for differences, where items ranked most highly indicated that respondents believed overweight people should be recognising a problem and acting on it, while the lowest rated items indicated that they also believed overweight people should also be accepted and not subjected to social pressures. Again, GPs showed significantly higher ratings of responsibility on nine of the 11 items (smallest F[1,247]=8.07, P<0.01), and again, this was the same for overweight and smokers.
Level of severity.
Only one significant level effect was found, with those at the extreme level perceived as more responsible for recognising a risk to their health (F[1,251]=14.1, P<0.001). To further explore the impact of level of severity in the overweight health category, independent t-tests were performed for the two levels of the overweight questionnaire. Significant differences were found for: ‘should recognise a problem exists’ (t=2.72, P<0.01); and ‘should recognise a risk to their health’ (t=4.38, P<0.001), where these were rated more highly at the extreme level.
Significant interaction effects were found for the items: should recognise that a problem exists, should recognise the risk to health, and should be encouraged to change (smallest F[1,251]=8.30, P=0.01). Thus, respondents perceived that moderate smokers were the most responsible and moderately overweight people were the least responsible for recognising that a problem exists, recognising a risk to their health, and being encouraged to change.
Mean responsibility score.
Cronbach's alpha for the 11 responsibility items was calculated as 0.90, thus indicating good internal reliability of the scale. When a two-way ANOVA was performed for the mean score in this section, smokers were rated significantly higher than overweight people (F[1,251]=142.8, P<0.001). Therefore, smokers were seen as more responsible for doing something to improve their health and were viewed as legitimate targets for not being accepted and being subjected to external pressures to change. A significant interaction (F[1,251]=10.5, P<0.001) revealed that moderately overweight people were perceived as the least ‘responsible to act’ of all four groups. However, since all groups scored at or above the scale mid-point the general perception was of individual responsibility.
As expected, health professionals attributed a variety of causes to overweight and obesity. However, these were not ostensibly more controllable than those factors attributed to smoking. It could be argued that a person's level of physical inactivity is within the control of the individual, whereas interpersonal factors are less so. In addition, the greater importance placed on mood and depression in the overweight group may relate to beliefs of emotional problems associated with weight gain, which implies the kind of character failing previously indicated in the literature. However, genetic factors, which are beyond the control of the individual, were also rated as important and considerably (significantly) more so than for smoking. Also, there were a number of similarities in the ratings for both overweight and smoking: addiction, personality, interpersonal factors and mood-related factors were rated as important. Perceived lack of willpower, so often noted as contributing to negative attitudes towards overweight people, was rated only marginally (non-significantly) more important in causing someone to be overweight than to be a smoker. Overall, this suggests a mixed pattern of beliefs that does not lend itself to the conclusion that the causes of overweight are seen as more controllable than the causes of smoking. Thus the first hypothesis cannot be accepted. Furthermore, smokers were rated as more personally responsible and less accepted than overweight people, so that the second hypothesis must also be rejected.
It is interesting to note that beliefs about the causes of overweight and smoking were not influenced by the level of severity of the category. Likewise, perceptions of personal responsibility indicated few level effects (so that the third hypothesis must be rejected). On the other hand, there were clear level effects for attitudes, with those at the more severe end of the scale generally viewed more negatively (so that the fourth hypothesis can be accepted). In line with the final hypothesis, obese people were rated most negatively of all groups, albeit rarely extremely negatively.
In summary therefore, the key views of health professionals in relation to overweight and obese people are that overweight (both levels) was seen as having mixed causes, that overweight people were seen as somewhat responsible to do something about their situation (but not as responsible as smokers), and by perceptions that overweight people had reduced self-esteem, sexual attractiveness and health. It is these latter three aspects that also appear to distinguish views of obese people from views of overweight people, as it is here that strong level effects were found. Despite previous speculations in the literature, the pattern of views found here does little to identify the key beliefs that may underpin negative attitudes towards obese people.
From the literature, the perception of reduced self-esteem may be based somewhat on truth: that some overweight people do experience difficulties in terms of self-esteem,12,29 although this is by no means a global finding.30 Accordingly, one would expect extremely overweight people to experience the least social acceptance because they are the least like the norm8 and the most difficulties in terms of self-esteem. This may explain why health professionals rated the esteem-related items more negatively for the extremely overweight group. Also, the findings for sexual attractiveness and health are in line with McArthur's finding of reasonably favourable attitudes among nutrition and non-nutrition students except in terms of the same two dimensions,19 and Agell and Rothblum's observation that appearance was one of only two out of eight factors which were rated negatively among psychologists.18 It is also in agreement with others who have reported that overweight is seen as unattractive.9,31,32,33,34
It needs to be remembered that extremely overweight people were not rated negatively for all items. For example, respondents did not view obese people as socially ‘different’ as they did smokers. Attitudes towards overweight people were not as bad as expected. Earlier, it was suggested that the negativity towards overweight people might have been overstated. That is not to say that the apparent widespread prejudice towards overweight people in Westernised countries does not occur among some health professionals. From the current data, attitudes appear to be mixed, with perceptions more likely to be negative the further away from the norm the overweight person is seen to be.
There are a number of limitations to the study that need to be taken into account in interpreting the results. First, there is the possibility of bias. For example, health professionals are known to report better practices than they actually undertake, even when they are aware their behaviour is being monitored and the clinical area is less subject to social bias.35 It could be argued that obesity prejudice is thus understated in these findings. Similarly, a response bias may have operated in that respondents may have been more interested in or favourably disposed to the health category they rated than were non-respondents. Nevertheless, it is the case that many previous studies have been subject to similar sources of bias, and so the findings relative to these would appear to hold true.
Secondly, the use of a comparison group is relatively unusual and may have acted as a balance to prevent over-interpretation of the relationships within the overweight data set. On the other hand it may have been preferable to compare health professionals' obesity beliefs and attitudes to those of patients in general. This was not possible within the confines of this methodology, but other techniques such as vignettes or videos in which body weight is manipulated may be more appropriate to this aim.
Thirdly, the measurement of obesity beliefs and attitudes suffers from a lack of validated assessment instruments. It is conceivable that the questionnaire did not measure what it set out to measure. This is especially likely in the case of the ‘responsibility’ scale, which has not been tested elsewhere. However, tests for reliability and use of principle components analysis suggested the attitude and responsibility scales had good internal consistency and appeared to be measuring similar concepts across the two health areas. It is still possible that the questionnaire failed to tap into other salient views held by health professionals.
Finally, the generalisability of the findings is dependent on response rate. Although there is no universally accepted level for defining an adequate response rate, there is a view that it should be as high as possible, and that the need for a high response rate is linked to the purpose to which the findings will be put. The response to this survey was not high, although within the confines of available resources it is difficult to determine how it could have been improved. Two reminders were used, a financial incentive, and authoritative letter-headed paper. Until recently, due to the lack of empirical evidence, survey design and administration had been based on experience and conventional wisdom. However, a structured review of survey methods has summarised the available evidence.36 This review suggests that the approaches used in the present study should have been useful in enhancing response rates. It also suggests that if the questionnaire covering letter had been signed by someone known and respected by respondents, rates may have been further improved.
The following conclusions may be drawn from the study. Health professionals' perceptions of moderately overweight people were relatively favourable, but attitudes towards extremely overweight (obese) people indicated room for improvement. Social desirability bias associated with self-report measures means that positive perceptions of moderately overweight people can not be taken for granted, and negativity towards extremely overweight people could be more pronounced. The perception of low self-esteem and reduced sexual attractiveness and health appears to encapsulate the dimensions of attitudes towards obesity which were most negative. There was no clear pattern of beliefs (causes and responsibility) which described the observed differences in attitudes for the two weight levels. This pattern of attitudes has not been described specifically elsewhere, and therefore it is difficult to speculate about what impact this may have on professional practice.
It is worth bearing in mind that attitudes towards obese people were not overwhelmingly negative. Nevertheless, a priority in future studies would be to consider weight level effects and in particular the negative views' professionals may have of obese people. Given that obese people are at greater risk of associated health problems, this is doubly important. Treatment is vital, and barriers to good treatment such as negative attitudes or patients' reticence to visit professionals who treat them with disregard, must be addressed. Well-designed studies to improve obesity management would do well to build in a dimension for improving providers' perceptions of the target group.
Maddox GL, Back K, Liederman V . Overweight as social deviance and disability J Health Soc Behav 1968 9: 287–298.
Breytspraak LM, McGee J, Conger JC, Whatley JL, Moore JT . Sensitizing medical students to impression formation processes in the patient interview J Med Educ 1977 52: 47–54.
Blumberg P, Mellis LP . Medical students attitudes toward the obese and the morbidly obese Int J Eat Disord 1985 4: 169–175.
Price JH, Desmond SM, Krol RA, Snyder FF, O'Connell JK . Family practice physicians beliefs, attitudes, and practices regarding obesity Am J Prev Med 1987 3: 339–345.
Bagley CR, Conklin DN, Isherwood RT, Pechiulis DR, Watson LA . Attitudes of nurses toward obesity and obese patients Percept Motor Skills 1989 68: 954.
Peternelj-Taylor CA . The effects of patient weight and sex on nurses' perceptions: a proposed model of nurse withdrawal J Adv Nurs 1989 14: 744–754.
Oberrieder H, Walker R, Monroe D, Adeyanju M . Attitude of dietetics students and registered dietitians toward obesity J Am Diet Assoc 1995 95: 914–916.
Young LM, Powell B . The effects of obesity on the clinical judgments of mental health professionals J Health Soc Behav 1985 26: 233–246.
DeJong W, Kleck RE . The social psychological effects of overweight. In: Herman CP, Zanna MP, Higgins ET (eds). Physical appearance, stigma and social behaviour: The Ontario Symposium Vol 3: Lawrence Erlbaum: Hillsdale, NJ 1986 65–87.
Crandall CS . Prejudice against fat people: Ideology and self-interest J Pers Soc Psychol 1994 66: 882–94.
SIGN (Scottish Intercollegiate Guidelines Network) . Obesity in Scotland: integrating prevention with weight management A national clinical guideline recommended for use in Scotland by the Scottish Intercollegiate Guidelines Network. SIGN: Edinburgh 1996.
Stunkard AJ, Wadden TA . Psychological aspects of severe obesity Am J Clin Nutr 1992 55: 524S–32S.
Frank A . Futility and avoidance. Medical professionals in the treatment of obesity JAMA 1993 269: 2132–2133.
HEA, Health Education Authority's National Unit for Health Promotion in Primary Care . Obesity in primary health care: a literature review Health Education Authority: London 1995.
Glanville G, Glenny A-M, Melville A, O'Meara S, Sharp F, Sheldon T, Wilson C . The prevention and treatment of obesity NHS Centre for Reviews and Dissemination. Effective Health Care Bulletin Churchill Livingstone: Edinburgh 1997.
Glenny A-M, O'Meara S, Sheldon T, Wilson C . The treatment and prevention of obesity: a systematic review of the literature Int J Obes Relat Metab Disord 1997 21: 715–737.
The National Heart, Lung, and Blood Institute . Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: The evidence report National Institutes of Health: Bethesda, MD 1998http://www.nhlbi.gov/nhlbi/cardio/obes/prof/guidelns/ob_home.htm
Agell G, Rothblum ED . Effects of clients obesity and gender on the therapy judgements of psychologists Profess Psychol Res Pract 1991 22: 223–229.
McArthur LH . Nutrition and nonnutrition majors have more favorable attitudes toward overweight people than personal overweight J Am Diet Assoc 1995 95: 593–596.
McArthur LH, Ross JK . Attitudes of registered dietitians toward personal overweight and overweight clients J Am Diet Assoc 1997 97: 63–66.
Robinson BE, Bacon JG, O'Reilly J . Fat phobia: Measuring, understanding and changing anti-fat attitudes Int J Eat Disord 1993 14: 467–480.
Harris MB, Hopwood J . Attitudes toward the obese in Australia J Obes Weight Regul 1982 2: 107–120.
Jarvie GJ, Lahey B, Graziano W, Framer E . Childhood obesity and social stigma: what we know and what we don't know Dev Rev 1983 3: 237–273.
Allison DB, Basile VC, Yuker HE . The measurement of attitudes toward and beliefs about obese persons Int J Eat Disord 1991 10: 599–607.
Troiano RP, Frongillo EA, Sobal J, Levitsky DA . The relationship between body weight and mortality: a quantitative analysis of combined information from existing studies Int J Obes Relat Metab Disord 1996 20: 63–75.
Bray GA, York B, DeLany J . A survey of the opinions of obesity experts on the causes and treatment of obesity Am J Clin Nutr 1992 55: 151–154.
Kinnear PR, Gray CD . SPSS for Windows made simple Lawrence Erlbaum: Hove, UK 1994.
Bryman A, Cramer D . Quantitative data analysis for social scientists Routledge: London 1990.
Crandall C, Biernat M . The ideology of anti-fat attitudes J Appl Soc Psychol 1990 20: 227–243.
Friedman MA, Brownell KD . Psychological correlates of obesity: moving to the next research generation Psychol Bull 1995 117: 3–20.
Lerner RM, Gellert G . Body build identification, preference, and aversion in children Dev Psychol 1969 5: 256–262.
Beck SB, Ward-Hull CI, McLean PM . Variables related to women's somatic preferences of the male and female body J Pers Soc Psychol 1976 34: 1200–1210.
Lavrakas PJ . Female preferences of male physiques J Res Personal 1975 9: 324–334.
Rothblum ED, Miller CT, Garbutt B . Stereotypes of obese female job applicants Int J Eat Disord 1988 7: 277–283.
Lomas J, Anderson GA, Domnick-Pierre K, Vayda E, Enkin M, Hannah WJ . Do practice guidelines guide practice? The effect of a consensus statement on the practice of physicians New Engl J Med 1989 321: 1306–1311.
McColl E, Jacoby A, Thomas L, Soutter J, Bamford C, Garratt A, Harvey E, Thomas R and Bond J . Designing and using patient and staff questionnaires. In: Black N, Brazier J, Fitzpatrick R, Reeves B (eds). Health services research methods: a guide to best practice BMJ Books: London 1998.
We are grateful to the Max Hamilton Memorial Fund, University of Leeds, for providing a grant to support this research. Particular thanks are due to the general practitioners and clinical psychologists who contributed to this survey, and to Drs Nigel Rice, Philip Young (both University of York), and Louise Dye (University of Leeds) for statistical advice.
About this article
Cite this article
Harvey, E., Hill, A. Health professionals' views of overweight people and smokers. Int J Obes 25, 1253–1261 (2001). https://doi.org/10.1038/sj.ijo.0801647
- health professionals
Journal of Eating Disorders (2019)
A new era of addiction treatment amplifies the stigma of disease and treatment for individuals with obesity
International Journal of Obesity (2016)
An obesity educational intervention for medical students addressing weight bias and communication skills using standardized patients
BMC Medical Education (2014)
Nurses’ self-efficacy and practices relating to weight management of adult patients: a path analysis
International Journal of Behavioral Nutrition and Physical Activity (2013)
BMC Research Notes (2011)