Weight-teasing is a widespread phenomenon that begins in childhood and can promote the internalization of anti-fat bias. An extensive literature illustrates the negative psychological, physiological, and social consequences for individuals experiencing weight-related stigma and discrimination. Adolescents are thought to be particularly vulnerable to mechanisms contributing to weight retention and weight gain through embodiment of weight-related stigma.

Prior research indicates that explicit and implicit fat bias are not strongly correlated in the United States, but whether explicit fat bias, implicit fat bias, or the relationship between the two varied in different epidemiological contexts within the US (ie, high vs low obesity prevalence) is less well-studied. For a study published in Pediatric Obesity, I sought to discern how obesity prevalence is related to fat bias. To do this, explicit and implicit fat bias in adolescents from two populations living in the same state, but in counties varying by obesity prevalence, were compared. Explicit fat bias refers to biased attitudes towards individuals with excess body fat that are conscious, and it was measured using the Attitudes Towards Obese Persons (ATOP) scale. Conversely, implicit fat bias refers to unconscious beliefs about body fat that people may be unwilling or unable to consciously self-report, and it was measured using the obesity attitude implicit association test (IAT).

Explicit Vs Implicit Fat Bias

Differences between explicit and implicit fat bias were observed (Table). Both samples reported relatively positive attitudes toward obesity in the ATOP, but they also demonstrated high levels of unconscious anti-fat bias in the IAT. Furthermore, implicit anti-fat bias was significantly higher in the sample with lower prevalence of obesity, suggesting epidemiologic context may influence implicit fat bias. It could be that higher obesity prevalence may reduce unconscious anti-fat bias in a population or, alternatively, that lower obesity prevalence may increase such bias.

Positive explicit attitudes appearing alongside implicit anti-fat bias in the US is likely indicative of the desire to be, or appear to be, unbiased or unprejudiced. The similarity in ATOP scores suggests shared cultural norms in the two populations, with relatively positive attitudes toward people with obesity representing the socially accepted norm. The shared pattern of discrepancy between explicit versus implicit fat bias, on the other hand, also suggests similarities in implicit attitudes, with both samples displaying high levels of unconscious anti-fat bias.

It is particularly salient that the sample with higher obesity prevalence had lower (although still anti-fat) implicit fat bias than those in the population where obesity is less common. This difference in implicit attitudes may be due to variation in exposure to different distributions of modal body types. Close contact or increased exposure to particular traits are thought to play a significant role in shifting normative beliefs around what is deemed acceptable.

Unconscious Anti-Fat Bias Lurking in the Background

What the results make clear is that even though people might agree that our explicit attitudes toward people with obesity should be relatively positive, unconscious anti-fat bias may still be lurking in the background, regardless of obesity prevalence within a population. This can be particularly harmful since implicit bias, compared with explicit bias, is hypothesized to be more closely related to ill health from psychosocial stress by being a larger driver of instances of discrimination and prejudice. This is particularly salient for adolescents experiencing weight stigma, as youth are thought to be especially vulnerable to internalization of such experiences. Physicians treating adolescents with overweight/obesity should take note that even in seemingly fat-positive environments, their patients may be regularly experiencing weight stigma, and this is likely exacerbated in regions where obesity prevalence is relatively low.

Future research on this topic should sample from more ethnically diverse populations, control for socioeconomic status, and measure height and weight directly. The results from this study highlight the importance of future research examining health disparities that may arise from the internalization of psychosocial stress related to experiences with fat stigma among those living in different epidemiologic contexts within the US.