www.whijournal.comWomen’s Health Issues 19 (2009) 289–291

INVITED COMMENTARY

NOT ALL ARE CREATED EQUALDifferences in Obesity Attitudes Between Men and Women

Christine Ferguson, JD, Sarah Kornblet, JD, MPH, and Anna Muldoon*

School of Public Health and Health Services, Department of Health Policy, George Washington University, Washington, DC

Received 26 June 2009; revised 1 July 2009; accepted 2 July 2009

Obesity has been getting a lot of attention thesedays. As the relationship between obesity and

diseases such as type 2 diabetes, cardiovascular dis-ease, and certain cancers has become clearer, theeconomic and social imperative to aggressively attackobesity has intensified. Our children may be the firstgeneration to live shorter lives than their parentsmay (Olshansky et al., 2005). Obesity is a contributingfactor to sky-rocketing health care costs. Nearly 80% ofobese adults have diabetes, coronary artery disease,high cholesterol levels, high blood pressure,gallbladder disease, or osteoarthritis (Must et al.,1999). Further, obesity connects to approximately400,000 deaths per year and has approximately thesame effect on the presence of chronic conditions as20 years of aging (Sturm, 2002). Yet, the stigmasurrounding the issue prevents us from addressing itas aggressively as we should.

Obese individuals face multiple forms of prejudiceand discrimination because of their weight (Puhl &Heuer, 2009). Nonetheless, studies in the past havemade it clear there are significant, measurable differ-ences in how much men versus women feel stigma-tized by obesity. Although there is a negative biastoward obese people in general, several studies haveexamined gender differences in perceived stigma andquality of life among obese patients, with most studiesfinding women experiencing significantly more nega-tive social and psychological effects from obesity. Astudy of obese individuals applying for bariatric sur-gery showed women, although having lower body

* Correspondence to: Anna Muldoon, George Washington Uni-versity, School of Public Health and Health Services, Departmentof Health Policy, 2021 K Street NW, Suite 800, Washington, DC200006; Phone: 202-994-4224.

E-mail: anna.muldoon@gwumc.edu.

Copyright � 2009 by the Jacobs Institute of Women’s Health.Published by Elsevier Inc.

mass index (BMI) overall, expressed significantlylower quality of life scores on self-esteem, sexual life,and public distress categories, leading to a clear con-clusion that women experience significantly more neg-ative perceived quality of life effects than their malecounterparts (White, O’Neill, Kolotkin, & Byrne,2004). A UCLA study found that women are muchmore likely to consider themselves overweight thanmen, regardless of BMI, but were less likely to exhibitsedentary behaviors psychologically linked to higherBMI (Yancey et al., 2006). Further, an obesity expertin the United Kingdom found patients who are obesemay avoid or delay seeking life-saving treatment androutine screening examinations because they fearbeing judged about their weight by medical staff(BBC News, 2009).

There have also been found to be differences betweenphysician attitudes toward male and female patientswith similar BMI: Physicians were more likely to recom-mend weight loss for women with normal BMI than formen with the same BMI, while being more likely to rec-ommend treatment for men with an obese BMI than forwomen (Anderson et al., 2001). Not only are there differ-ences between men and women around perceivedstigma, but several studies have also found obesewomen face significantly more wage discrimination inemployment than both their normal weight counter-parts and obese men (Puhl & Brownell, 2001). In onestudy of overweight and obese women, 25% of partici-pants reported experiencing job discrimination becauseof their weight (Puhl & Brownell, 2006). In addition, 54%reported weight stigma from co-workers or colleaguesand 43% reported experiencing weight stigma fromtheir employers or supervisors (Puhl & Brownell,2006). It is important to understand the nature of thesedifferences and how they affect the behavior of theindividual to appropriately tailor interventions.

1049-3867/09 $-See front matter.doi:10.1016/j.whi.2009.07.001

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It was an interest in what is happening in the work-place that led the Strategies to Overcome and Prevent(STOP) Obesity Alliance and the National OpinionResearch Center (NORC) to conduct a study of em-ployer and employees attitudes toward obesity inter-ventions at work. Although the goal of the study wasto examine differences in attitudes on obesity betweenemployers and employees, and the programs in exis-tence within companies to address obesity, what wefound were interesting differences between genders.We completed the survey in the fall of 2007 and thespring of 2008, and included public and private firmswith 50 or more workers who offered health benefits(Gabel et al., 2009). In terms of employees, questionswere done was part of the EXCEL Omnibus Survey,International Communications Research of U.S. house-holds and included a supplement on obesity. Therewere interviews with over 1,300 people who wereemployed either full or part time by a company with50 or more employees, and were enrolled in eitheremployer- or union-sponsored health insurance.

Overall, employees supported the existence ofweight management programs within their compa-nies, but there were some significant differencesbetween the views of men and women. Women weresignificantly less likely to believe overweight or obeseemployees are less productive than other employees(27% of women vs. 42% of men). There was also a gen-der difference in the likelihood of believing that weightmanagement programs belong in the workplace, with84% of women and 76% of men agreeing. Womenwere also much more optimistic about programssuch as Weight Watchers, with 42.5% of women sayingthey are useful and only 27% of men. Finally, womenwere more likely to believe that subsidizing healthyfoods reduces obesity, with 55% of women saying it‘‘frequently helps’’ and only 38.8% of men agreeingwith this statement. These results are especially inter-esting given the fact research shows women in generaltend to have more of a weight bias than men do (Puhl &Heuer, 2009).

The question then becomes, why are women moreopen to addressing the issue of obesity at work thanmen seem to be, especially given the fact they tend tobe more biased on the issue? One possible explanationfor women’s reaction to workplace interventions iswomen tend to have less free time than men (especiallythose women in the workplace), and they may feela stronger push to make lifestyle interventions avail-able in an arena they already occupy. Combining thisreasoning with the information regarding the socioeco-nomic and gender predictors of obesity, it is logical topropose that workplace interventions may havea stronger effect on women’s ability to exercise andaccess weight management programs than on men’s.The study conducted with NORC shows women areboth more open to and more optimistic about the

possibility of controlling weight through diet and life-style interventions and are also more likely to believethat weight management programs and healthy foodsbelong in the workplace.

Based on current research, the STOP ObesityAlliance has proposed a series of policies to addressobesity and overweight that may have significantimpacts for women in particular. One goal is to rede-fine success in weight loss efforts as a sustained 5%to 10% weight loss over time. According to theNational Heart, Lung, and Blood Institute of theNational Institutes of Health (NIH), this goal providessignificant health benefits and is a much more achiev-able level of weight loss for most patients (NIH, 2009).Redefining success in terms of health is not an easyprocess and may be particularly hard for womenbecause of the social pressures for thinness. This goaldoes not focus specifically on a ‘‘normal weight,’’rather it focuses on improving the overall health ofoverweight and obese patients without creatingunachievable goals that may lead to frustration andhigher dropout rates for weight loss treatments. Con-sidering the negative health effects of repeated, unsuc-cessful, so-called yo-yo dieting, creating goals thatencourage patients to maintain smaller amounts ofweight loss could have stronger medical and psycho-logical benefits than the current focus on achievinga normal BMI alone.

The alliance views stigma and discriminationagainst overweight and obese individuals as a majorbarrier to treatment and argues interventions need toaddress both the medical and social aspects of obesityto be successful. Obese patients who feel stigma fromtheir physicians may be less likely to return to the doc-tor, which will in turn mean they are less likely toreceive treatment both for obesity and for comorbidconditions (Puhl & Heuer, 2009). At the same time,physicians who do counsel obese and overweightpatients need to be particularly aware of weight stigmaand the need to focus on both medical and psycholog-ical aspects of treatment. Particularly for women,a focus on achieving appearance-related goals fails totake into account the level of social stigma thesepatients experience because of their weight and mayreinforce the idea that failing to reach a normal BMIwill prevent them from improving their quality of life.

Although many of the behavioral, social, economic,and cultural aspects of obesity have been identified, ge-netic and environmental factors, among others, are stillcoming to light. It is also clear the social and behavioralcauses of obesity are complex and must be dealt withcarefully so as to avoid an increase in stigma and the per-sonal responsibility theories placing the blame for obe-sity on individuals. Obesity is a problem caused byvarious aspects of our society and, thus, the solutionmust be multifactorial as well. We must take advantageof the current discussions around health reform and

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ensure obesity and effective interventions are includedas part of that discussion. New interventions mustaccount for gender and socioeconomic differences inparticular, both at the workplace and in a larger commu-nity context. Until we embrace the various aspects of thisproblem and recognize the need for a comprehensivesolution, we will continue down this dangerous roadleading us to a nation of obese individuals.

It is vital that, in the context of health reform, obesitynot be viewed as a separate excludable condition forinsurance benefits purposes, but rather viewed as a dis-ease. That is, a disease treatable in the same way ashigh blood pressure or high cholesterol. We mustensure in a health reform plan that obese and over-weight individuals have the assistance they need inlosing and maintaining a healthy 5% to 10% weightloss so the epidemic does not continue down the cur-rent trends. As discovered in the survey discussed,large employers are acknowledging the need for mul-tifactorial interventions in the workplace. Despite theU.S. Preventive Services Task Force making recom-mendations for clinicians to screen all adult patientsfor obesity and offer counseling and behavioral inter-ventions to promote sustained weight loss for obeseadults (Wood et al., 2009), the health care systemdoes not yet support these services. It is time for thefederal government to refine health care in support ofsuch recommendations. To exclude certain interven-tions designed to support someone receiving otherservices for obesity-related diseases and yet not obesityitself is like shooting ourselves in the foot.

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Author DescriptionsChristine C. Ferguson, JD, is a Research Professor in

the Department of Health Policy of the George Wash-ington University School of Public Health and HealthServices and the Director of the STOP Obesity Alliance.Her research focuses on obesity, health care reform,Medicaid, and state health policy.

Sarah Kornblet, JD, MPH, is a recent graduate of theGeorge Washington University School of Public Healthand Health Services. She currently serves as a SeniorResearch Assistant for the Department of Health Policy,focusing on obesity policy and international health.

Anna Muldoon is a Research Assistant and MPHcandidate at the George Washington University Schoolof Public Health and Health Services, focusing onobesity policy, international health, and infectiousdisease.