ANTI-FAT ATTITUDE INTERVENTION
6.1. Introduction
Anti-fat attitudes have been reported across a range of groups and in a variety of contexts, for
example in employment contexts and in interpersonal encounters (e.g., Puhl & Brownell,
2001). O’Brien et al. (2010) reported strong evidence of employment related discrimination
towards the obese, such as rating obese candidates for a job as having less leadership
potential and a lower likelihood of being employed than a normal weight person. In an
interpersonal context, Bessenoff and Sherman (2002) examined how far individuals chose to
sit from an obese individual and demonstrated that those with more negative implicit attitudes
sat further away from the obese person. These studies demonstrate discrimination towards the
obese population and support suggestions that this form of discrimination is evident in
society today and reflects society’s anti-fat attitudes (e.g., Carr & Friedman, 2005). Although,
causal links between anti-fat attitudes and discrimination have not yet been fully established,
recently O’Brien et al. (2010) provided some evidence to suggest there is an association.
Thus, strategies and interventions are clearly required that aim to reduce anti-fat attitudes if
these contribute to discrimination against the obese.
The formation of attitudes is a well established area of research in social psychology (Olson
& Fazio, 2001). It is thought that attitudes develop as a result of pairings of potential attitude
objects (conditioned stimuli) with positive or negative stimuli (unconditioned stimuli), which
results in either positive or negative attitudes towards an object (Olson & Fazio, 2001), for
example, pairing fire with being burnt. Olson and Fazio stated that through this classical
conditioning racial prejudice may be developed where there are “media portrayals of
minority-group members in a negative fashion” (p. 413). Prejudice towards fat people has
been demonstrated in a variety of contexts and in some research has been shown to surpass
that of other commonly stigmatised groups such as homosexuals (Latner et al., 2008; Latner
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& Stunkard, 2003). Anti-fat attitudes are of great concern given the potential influence they
have on the health of the overweight and obese, where depression, low self esteem and in
some cases suicidal behaviours have been observed (Puhl & Heuer, 2009). Additionally, antifat attitudes may lower physical activity rates in obese individuals and decrease the likelihood
of them seeking healthcare treatment (Neumark-Sztainer, Falkner, Story Perry, Hannan, &
Mulert, 2002; Vartanian & Shaprow, 2008; Helb et al., 2003).
The Elaboration Likelihood Model (Petty & Wegener, 1986) is a model of persuasion and
attitude change which proposes two potential routes (central and peripheral) that can be used
to explain attitude change. Processing in the central route is complex and involves a
comprehensive analysis and the incorporation of relevant information (O’Brien et al., 2010).
In comparison, processing in the peripheral route is less intricate, where attitudes are
influenced by superficial aspects associated with the message such as source attractiveness
and credibility (O’Brien et al., 2010). Integral to the model and whether information is
processed through the cognitive or peripheral routes are motivation and ability. Those who
have high motivation as well as the ability to process information will utilise the central route
of processing instead of the peripheral route. Central route processing is argued to result in
stronger and more stable attitude change (O’Brien et al., 2010), whereas attitude change
through the peripheral route is thought to be weaker and less robust as a result of lesser
cognitive effort required with persuasive effect (Hague & White, 2005). Integral mechanisms
that dictate the route of processing: are motivation as an individual needs to be stimulated to
process the information and be open to attitude change; the ability to process the information
to ensure the message is attended to: the demonstration of a favourable or unfavourable
preference as indecisiveness leads to peripheral route processing, and, willingness to embed
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those preferences in memory. When these central route demands are not met, it is likely that
information will be processed through the peripheral route.
A plethora of research has examined attitude change in relation to the media and
advertisement and the role of persuasion in shaping existing attitudes (e.g., Petty, Cacioppo,
& Schumann, 1983). Attitude change that occurs through the central route results from
diligent consideration of information that is perceived to be paramount to the true merits of a
particular attitudinal stance (Petty et al., 1983). It is a result of this diligence to the
information that causes long term change in an attitude (Petty & Cacioppo, 1979; Petty et al.,
1983). Persuasion is suggested to have a stronger effect when information is processed
through the peripheral route, where diligent consideration is not required, but may occur
more simply because of a positive outcome or experience, or because of the credibility of the
information source, for example a nutritionist advising a person about food consumption
(Petty et al., 1983). Involvement is proposed to play a key role in attitude change and it is the
interplay between persuasion and involvement that dictates whether attitudes are shaped
effectively (Petty et al., 1983). It is suggested that high involvement messages have greater
personal relevance and consequences that are likely to elicit personal connections compared
with low involvement messages which are suggested to have lower personal importance
(Engel & Blackwell, 1982; Petty & Cacioppo, 1979). Petty et al. (1983) propose that there is
an inverse relationship between involvement and persuasion, where persuasion is more
important when involvement is low and less important when involvement is high. Thus
persuasion is less important in an attitude intervention that has high involvement and vice
versa.
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Reducing anti-fat attitudes is a major challenge but is of gross importance given the observed
effect of stigma on public health interventions and delays in seeking medical assistance for a
health condition because of a stigma or a fear of discrimination (Heijnders & Van Der Meij,
2006). In a review of stigma reduction strategies and interventions in the field of HIV/AIDS,
mental illness, leprosy, tuberculosis, and epilepsy Heijnders and Van Der Meij (2006)
indicated that there are a number of levels at which strategies can be implemented (e.g.,
community level) and that future research should consider the most appropriate level to
ensure an intervention will be most effective. They identify strategies at an Intrapersonal
level (treatment, counselling, cognitive-behavioural therapy), Interpersonal level (care and
support, home care teams, community-based rehabilitation), Organisational/institutional level
(training programmes, policies such as patient-centred and integrated approaches),
Community level (education, contact, advocacy) and Governmental/structural level (legal and
policy interventions, rights-based approaches).
The aims of these strategies differ: Intrapersonal level interventions are aimed at changing
specific characteristics displayed by an individual such as attitudes, knowledge and
behaviour; Interpersonal level interventions are aimed at establishing relationships within the
patients’ interpersonal environment to encourage the sharing and promotion of health;
Organisational/institutional level interventions aim to alter health and stigma related aspects
of an organisation to increase knowledge and appreciation of the effects of stigma;
Community level interventions aim to increase knowledge of health conditions and the
effects of stigma within community groups whilst developing skills, support networks and
services for victims to turn to; Government/Structural level interventions aim to enforce the
protection and rights of those who become stigmatised (Heijnders & Van Der Meij, 2006).
Whilst stigma reduction strategies may be implemented at these different levels, Deacon,
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Stephney, and Prosallendis (2004) suggest that victims should not be expected to carry the
burden of stigmatisation and that educating the general public and increasing their tolerance
is not enough, whilst Heijnders and Van Der Meij (2006) argue that interventions should
target a number of levels.
There is a lack of research conducted with the aim of reducing either implicit or explicit antifat attitudes and therefore there is a demand for interventions designed to reduce these
attitudes (Danίelsdόttir et al., 2010; O’Brien et al., 2010; Puhl & Heuer, 2009). These are
most important for those working in a healthcare environment with reports of healthcare
professionals failing to recommend treatment for obese patients (e.g., Price et al., 1987).
Different approaches have been utilised to reduce anti-fat attitudes such as alteration of
existing knowledge and beliefs about the causes and controllability of overweight and obesity
(e.g., Bell & Morgan, 2000; Diedrichs & Barlow, 2011; O’Brien et al., 2010) or through
evoking empathy with obese individuals (Gapinski et al., 2006; Teachman et al., 2003).
Interventions to reduce anti-fat attitudes have demonstrated varying effectiveness and
therefore alternatives need to be considered.
By altering existing knowledge about the causes and controllability of obesity, O’Brien et al.
(2010) demonstrated that both implicit and explicit anti-fat attitudes can be reduced in
healthcare professionals. Implicit anti-fat attitudes based on good/bad and motivated/lazy
associations using the IAT (Greenwald et al., 1998) were reduced, thus, individuals were less
likely to associate fatness with being lazy. A reduction was also observed in the dislike and
willpower subscales of the anti-fat attitudes scale (Crandall, 1994) suggesting that explicit
anti-fat attitudes can be reduced by altering existing knowledge about the controllability of
obesity. Other research has demonstrated a reduction in implicit but not explicit attitudes, for
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example, Teachman et al. (2003) reported overweight participants (BMI > 25kg/m2) implicit
attitudes diminished after evoking empathy towards an obese person. Additionally, other
studies have employed specific populations for example both Rukavina, Li, & Rowell (2006)
and O’Brien et al. (2010) used undergraduate students to alter beliefs about the controllability
of obesity as a mechanism to reduce anti-fat attitudes. Evidence supports a distinction
between implicit (automatic) and explicit (deliberate) attitudes and each predict different
types of anti-fat behaviour that may be physical, verbal or relational (e.g., Bessenoff &
Sherman, 2002; O’Brien et al., 2010), thus there is a clear demand for interventions that
target both types of attitude.
One research study that has shown promise in the reduction of anti-fat attitudes was
conducted by Hague and White (2005) using a web-based intervention based on the
principles of the Elaboration Likelihood Model (Petty & Cacioppo, 1986). Hague and White
employed an educational intervention incorporating a non-diet, health centred approach as
opposed to a weight centred approach to obesity management. The intervention was selfpaced and designed to last approximately five hours, where a picture of a woman from a webbased clothing catalogue was reused to create the images of a module leader. The original
image was reduced by approximately 25% for the “non-fat” presenter and increased by
approximately 20% for the “fat” presenter. The underlying premises of the intervention were
that students would scrutinise the message, be adequately motivated to attend to the message
and be willing to embed the message in memory and have a favourable or unfavourable
preference based on the intervention information. These premises are a requirement of central
route processing, thus the intervention was designed to change attitudes by processing
information through the central route. Both presenters were described in the same way, as
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having extensive professional knowledge in the field of nutrition at the beginning of the
intervention and were given the same credentials (PhD, Registered Dietician).
Results indicated a reduction in explicit anti-fat attitudes post intervention. It was also
reported that there was a greater positive effect on anti-fat attitudes when exposed to the “fat”
presenter as opposed to the “non-fat” presenter, suggesting that advice from a “fat” nutrition
expert had a more favourable effect on attitudes towards obesity than a “non fat” nutrition
expert. The findings however, do not support the Elaboration Likelihood Model (Petty &
Cacioppo, 1986), as Hague and White report that motivation and ability did not predict
attitude change thus processing was not solely through the central route and the favourable
change in attitudes occurred because of processing the messages provided as opposed to the
peripheral cues of presenter expertise or attractiveness thus nor did processing occur only
through the peripheral route. To explain the observed change in attitudes, it was suggested
that central and peripheral processing routes may work in tandem through moderate
elaboration, where evaluation of a strong message may be evaluated on the basis pertinent
information such as of the expertise of the presenter as opposed to more peripheral cues such
as their appearance.
Other research has examined the effect of evoking empathy as part of an intervention to
reduce weight bias (e.g., Harris, Walters, & Waschull, 1991; Teachman et al., 2003).
Teachman et al. (2003) examined implicit bias and stereotypes about overweight persons,
reporting an increase in implicit and explicit anti-fat prejudice in a non-empathy evoking
condition after exposing participants (members of the general public passing by) to a recently
published news article which informed them that obesity was caused by overeating and a lack
of exercise. This suggests that participants reported more anti-fat attitudes as a result of
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information about the controllability of the condition. However, in the empathy evoking
condition when exposed to information discussing the role of genetics in the development of
obesity and thus suggesting that the condition is out of the individual’s control, this did not
produce less implicit or explicit anti-fat prejudice in comparison to a control group, who only
completed the measures of attitudes towards obesity. A similar finding was also reported with
children exposed to videos of boys and girls of different body sizes, one of whom was an
obese child with a medical explanation provided for the condition (Bell & Morgan, 2000).
Although children attributed less blame towards the child with the medical explanation than
to the child without one, this did not affect a desire to engage with the obese children. Older
children however, had less desire to engage academically with the obese child, even when the
medical explanation for their condition was provided.
Recently, Deidrichs and Barlow (2011) demonstrated that anti-fat attitudes can be altered
using education based intervention to teach participants about weight bias and the multiple
determinants of weight. Participants were non-randomly assigned to three groups; control
who received no educational lecture (4th year health psychology course); intervention who
received a lecture on body image, obesity and weight bias to raise awareness and
consequences of weight bias and its consequences and to challenge beliefs about the
controllability of obesity (3rd year psychometrics course); and a comparison group who
received a lecture aimed to increase students knowledge of the risks of overweight and
obesity and treatment strategies (3rd year health psychology course). All participants
completed the Anti Fat Attitudes Test (AFAT; Lewis et al., 1997) in class and one week later
the intervention and comparison group received their educational intervention before
completing the AFAT for a second time. The control group also completed the AFAT one
week after completing the measure for the first time but received no educational lecture. All
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ANTI-FAT ATTITUDE INTERVENTION
three groups then completed the AFAT for a final time three weeks post intervention. This
study only measured explicit attitudes and therefore although a shift was observed, it is
unclear whether this intervention is effective for modifying implicit attitudes. Additionally, a
different presenter was used to administer the intervention and comparison conditions (i.e., a
young woman and a middle aged man), thus by not controlling for class leader, there is no
certainty that this effect was due to the intervention or the condition presenter. Finally, the in
class measurement used may have confounded the results where explicit responses are open
to response biases and demand characteristics (Rudman, 2004) and the number of students in
the class varied, therefore measures were completed in inconsistent contexts.
Two studies have additionally used counter conditioning alongside evoking empathy
(Gapinski et al., 2006; Wiese, Wilson, Jones, & Neises, 1992). The first was conducted by
Wiese et al. (1992) using a sample of first year medical students. They employed a variety of
conditions as part of the intervention: a video of an obese female discussing her experiences
of discrimination, written facts related to the relationship between the environment and
genetics in obesity and role-play where an obese person’s perspective was taken by the
participant. Weise and colleagues reported that beliefs about the controllability of obesity
reduced; however, it was unclear whether evoking empathy or counter conditioning was
responsible for this change. Despite not knowing which of the intervention conditions
produced the reduction in bias, results suggested that empathy may be an important tool to
reduce anti-fat attitudes. However, a recent review of anti-fat intervention studies
(Danίelsdόttir et al., 2010) has questioned the findings, suggesting that on closer inspection,
because of group differences evident at baseline, the results may not in fact reach
significance. Thus the effects reported by Wiese et al. may not be accurate.
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In the second study to examine evoking empathy and counter conditioning interventions,
Gapinski et al. (2006) exposed undergraduate students to four 10 minute videos and assessed
implicit and explicit attitudes reporting little evidence of an effect. A surprising finding
Gapinski and colleagues reported was a counterintuitive trend where exposure to a video of
an overweight woman depicted with negatively valenced stereotypical characteristics (e.g.,
unattractive, unintelligent, sluggish) lead to a decrease in explicit anti-fat attitudes. This
finding was suggested to be the result of excessive exposure to stereotypical videos and
therefore participants’ anti-fat attitudes decreased as a reactive response to the strong bias
occurring or because of the experimental situation which may have resulted in demand
characteristics.
There are limitations to both these studies that future research should account for when
examining anti-fat attitude interventions. First, future research should examine the
interventions separately to ensure that accurate conclusions concerning both interventions can
be drawn, as Wiese et al. were unable to determine which had an effect, and to avoid over
exposure which Gapinski et al. suggest may have contributed to the lack of effect observed.
Second, the formation of attitudes has elements of social desirability and therefore an
individual’s attitude is often similar to others’ around them. Furthermore, Rudman (2004)
suggests that explicit attitudes are susceptible to response biases and demand characteristics.
Thus, a major limitation of Gapinski et al. is that participants were exposed to the video
conditions and completed study measures in small groups and therefore this may have had an
effect on participants’ response to the conditions leading to the non-significant effects. As a
result of the limitations of the above studies, the effectiveness of counter conditioning for
changing anti-fat attitudes is still unclear and requires further examination.
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Only one other study has examined counter conditioning as an anti-fat attitude intervention,
however, this study could be interpreted as an intervention to reduce self decrement.
Robinson, Bacon, and Reilly (1993) examined whether fat phobia can be lowered by
reducing participants’ feelings of responsibility for their fatness with a sample comprising
87% overweight or obese treatment seeking women, thus as Danίelsdόttir et al. (2010)
suggest, this study represents a positive self affirmation intervention rather than one aimed at
reducing anti-fat attitudes. Nevertheless, this study has its merits and provides an initial
marker for research examining the reduction of system justifying anti-fat attitudes, which
Chapter 1 demonstrates are evident in UK adults.
To summarise the above research there appears to be limited evidence to suggest anti-fat
attitudes can be reduced by employing a specific intervention; however, there are some
encouraging findings (e.g., Teachman et al., 2003). To date there have been more attempts to
alter attitudes by employing interventions designed to modify existing beliefs about the
controllability of obesity however, mixed findings of the effectiveness of interventions have
been reported. Additionally, the majority of studies have used undergraduate student samples
and solely employed explicit measurement (e.g., Diedrichs & Barlow, 2011), which may
have confounded the effectiveness of the interventions, as a result of a greater awareness of
body shape ideals and in parallel stronger anti-fat attitudes as demonstrated in study 1. Thus
by using a student sample, this may reduce the likelihood of attitude change. Another
important limitation of the previous research examining anti-fat attitude reduction
interventions is that participants may have deduced the rationale for the study, thus this may
be one reason for some of the study findings reported. Thus, with the limitations of previous
research and the mixed success of anti-fat attitude interventions, it appears sagacious to
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examine whether successful interventions demonstrated as successful with other commonly
stigmatised characteristics are applicable to anti-fat attitudes.
Counter conditioning is a process by which existing attitudes can be altered through
subsequent conversely valenced affective experiences (Walther, Nagengast, & Trasselli,
2005). This method involves the pairing of a negatively perceived object or person with
positive characteristics and as a result of this pairing negative perceptions can be reduced.
Similarly, counter stereotypical exposure has also been suggested to reduce negative
perceptions or behaviour through imitation (Bigler, 1999). Counter conditioning has
previously been demonstrated to be an effective strategy for changing attitudes towards
stigmatised characteristics, such as racial attitudes (Bigler, 1999; Dasgupta & Greenwald,
2001; Litcher & Johnson, 1969) and reducing arachnophobia (De Jong et al., 2000).
Researchers examining attitude reduction for other stigmatised attributes have used a counter
conditioning intervention, such as Dasgupta and Greenwald (2001) who demonstrated that
implicit racial attitudes can be altered with this intervention. Dasgupta and Greenwald
presented participants with images of well known black and white individuals and reported a
stronger pro-black response after participants were exposed to admired black individuals. A
noteworthy finding was that the initial implicit white preference participants reported was
less when pro-black images were salient compared with non-racial or pro-white images. This
effect was observed immediately and remained evident after 24 hours. Importantly, although
implicit white preference was altered, participants’ explicit white preference remained
immediately and 24 hours after image exposure supporting the need to examine both forms of
attitude.
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The present study employed a counter conditioning intervention to reduce implicit and
explicit anti-fat attitudes towards and beliefs about obesity. In this case, the counter
conditioning strategy involved exposure to positive images of overweight and obese
individuals. This included images of overweight and obese celebrities who are perceived to
have positive qualities (e.g., strength, motivation, competence), as a means of altering
previous negative associations of being overweight or obese with new positive ones.
Celebrities are generally seen in a positive light where their attitudes and behaviours may be
imitated by the general public (Rucker & Petty, 2006), for example celebrities who endorse
products or brands have been shown to improve sales (e.g., Agrawal & Kamakura, 1995). It
is expected that as a result of the positive affiliation individuals have with celebrities,
exposure to overweight and obese celebrities would also reduce anti-fat attitudes by
association of the positive feelings towards celebrities with their physical characteristics, thus
their appearance.
To the researcher’s knowledge, it was not until very recently that the effects of obesity
images in the media on anti-fat attitudes have been studied. Swami et al. (2008) examined the
effects of exposure to photographs of ‘real people’ demonstrating that stigmatisation was
greater as BMI increased. These authors also reported that overweight men and women were
judged to be lazier, lonelier and more teased than those of a lower BMI. McClure et al.
(2011) demonstrated that news stories accompanied by an image of an obese person resulted
in more negative anti-fat attitudes when the image depicted a stereotypical portrayal as
opposed to a non-stereotypical portrayal, irrespective of the story content (McClure et al.,
2011). Unlike McClure et al. (2011) who compared stereotypical images of stereotypes of the
obese (e.g., lazy) and non-stereotypical images, the current study solely employed positive
non-stereotypical pictures of overweight and obese persons (e.g., fitness instructor). The
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present study also used images of the general public to compare the effect with that of
celebrity images when presented with non-stereotypical overweight and obese targets.
The aim of this study was to examine whether implicit and explicit anti-fat attitudes towards
obesity can be reduced through a counter conditioning intervention. The study was designed
to shed light on a potential intervention that may be used to reduce anti-fat attitudes. The
study also aimed to compare the effects of exposure to images of overweight and obese
celebrities and the general public.
The main hypothesis for the present study was that participants will report reduced anti-fat
attitudes when exposed to positive images of overweight and obese celebrities and of obese
members of the public compared with baseline attitudes. It was further hypothesised that this
effect would be greatest when exposed to images of overweight and obese celebrities. These
hypotheses are based on the premise that counter conditioning can change existing attitudes
as demonstrated in previous research (e.g., Dasgupta & Greenwald, 2001). Thus, participants
anti-fat attitude is expected to reduce as a result of the positive associations formed between
celebrities and overweight and obesity.
6.2. Method
6.2.1. Participants
An opportunity sample consisting of 17 males and 11 females aged 18-35 years was
recruited. Participants had a mean BMI of 23.83 ± 3.25kg/m2 and exercised on average 6
hours 11 minutes per week. All participants were connected to the University (Students,
lecturers, non-academic staff, a technician and a science consultant).
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6.2.2. Measures
Participants were required to complete a battery of questionnaires (IAT: Greenwald et al.,
1998; ATOP & BAOP: Allison et al., 1991; AFAS: Morrison & O’Connor, 1999; F-scale
(Bacon et al., 2001; three terminology questions about the interpretation of fat and obese
labels) on three separate occasions (see section 3.2.2 for measures).
6.2.3. Procedure
Participants attended the laboratory on three separate occasions, to complete the IAT
(Greenwald et al., 1998) and a set of explicit measures: ATOP and BAOP (Allison et al.,
1991), the F-scale (Bacon et al., 2001), and the AFAS (Morrison & O’Connor, 1999). The
orders of the experimental conditions and completion of the measures within the three
conditions were counterbalanced, although visit one was a baseline condition for all
participants. The first visit involved completing an informed consent form (see appendix 6.1),
demographic questions (see appendix 6.2) and all measures to provide baseline scores. In the
two experimental conditions, participants were exposed to a slideshow containing images of
overweight and obese people (with images of celebrities in the celebrity images condition and
with positive images of the public in the public images condition). Unlike the public images
condition, the celebrity images were accompanied by a brief description detailing some of
their achievements and reasons why the individuals are credible in an attempt to reinforce
positive affiliation with the celebrities depicted. All images in the public condition were nonstereotypical images of overweight and obese individuals, for example a fitness instructor,
deviating from the lazy stereotype often associated with overweight individuals. There were
31 images of celebrities (male 20, female 11; see Appendix 6.3) and 22 images of the public
(male 11, female 11; see Appendix 6.4).
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Participants were instructed to take in the image and read all of the descriptions on each of
the slides before proceeding to the next slide. Participants were asked to go through the slide
show once in the celebrity images condition and twice in the public images condition in an
attempt to increase contact time with the public images and to increase the likelihood of
participants processing and attending to the underlying message. Following exposure to the
relevant images participants completed the attitude measures as described above. Participants
viewed the slideshows and completed all measures behind a screen so that the experimenter
was not visible in an attempt to reduce any effects of experimenter presence.
6.2.4. Data Analysis
IAT D scores, representing the difference between response latency for different associations
(i.e., fat with pleasant paired with thin with unpleasant and fat with unpleasant paired with
thin with pleasant), were calculated as recommended by Greenwald et al. (2003). D scores
and explicit attitude scores were compared between the three conditions (baseline, public
images, celebrity images) using one-way repeated measures ANOVAs with Bonferroni
correction for confidence interval adjustment and post-hoc tests with Sheffé correction to
examine any main effect differences.
6.3. Results
6.3.1 Descriptive Statistics
Combined Cronbach’s alpha coefficients for the three conditions for the explicit measures
were as follows: ATOP = .83, BAOP = .70, AFAS = .75 and F-Scale = .89. Examination of
normality indices for the scales revealed that the ATOP (Z score for skewness = .08, kurtosis
= -.05), AFAS (Z score for skewness = .61, kurtosis = -1.11), and F-Scale (Z score for
skewness = .41, kurtosis = -.55) met the assumption of normality although the BAOP violated
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this assumption (Z score for skewness = 4.51, kurtosis = 5.10). For the additional questions
pertaining to the interpretation of the labels ‘fat’ and ‘obese’ Question 2 violated the
assumptions of normality (skewness = 1.19, kurtosis = -2.23), whereas Question 3 met the
assumption of normality (skewness = -1.24, kurtosis = -1.29). The IAT also violated the
assumption of normality (Z-score: skewness = 4.63, kurtosis = 4.01).
6.3.2 Assumptions of the Statistical Tests
One-way repeated measures ANOVA: see Section 3.3.2. Dependent variables were measured
on an interval scale and were independent meeting the assumptions of the test. The Z-Scores
for skewness and kurtosis reported above demonstrate that not all dependent variables met
the normality assumption, with the BAOP, IAT, and Question 2 violating this assumption.
Field (2009) likens the assumption of sphericity to that of homogeneity of variance in a
between subjects design. Mauchly’s test of sphericity indicated that the ATOP, BAOP, FScale, Question 2 and the associations of fat with pleasant/thin with unpleasant and fat with
unpleasant/thin with pleasant met this assumption, whereas the AFAS, Question 2 and 3
violated the assumption of sphericity (see Appendix 6.5). Whilst some of the above
assumptions were violated, the F test in ANOVA is sufficiently robust to account for these
(Field, 2009), for example, Glass, Peckham, and Sanders (1972) claim that the F test in
ANOVA can still be performed when data are skewed and that transforming data is as much
of a hindrance as a help.
6.3.3 Implicit Attitude Data
Participants demonstrated negative attitudes towards obesity in all three conditions (IAT D
score; Baseline = 0.69, Celebrity = 0.82, Public = 0.77). However, although there was no
significant difference in IAT D scores between conditions (Table 6.1).
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ANTI-FAT ATTITUDE INTERVENTION
6.3.4 Explicit Attitude Data
Table 6.1: Means and standard deviations of explicit and implicit measures of perceptions of
obesity in relation to baseline, celebrity and public conditions
Variable (range)
Baseline
Celebrity
Public
IAT D
.69
.82
.77
Score
(.54)
(.41)
(.40)
ATOP
60.93
59.11
59.32
(0-120)
(12.95)
(16.94)
(16.87)
BAOP
12.11
12.64
12.75
(0-48)
(4.47)
(5.06)
(7.33)
AFAS
17.45
17.93
17.71
(0-25)
(3.43)
(3.43)
(3.40)
F-Scale
4.03
3.98
3.99
(0-5)
(.47)
(.50)
(.47)
Q2
7.54
8.07
7.75
(1.45)
(1.33)
(1.35)
6.50
6.64
7.11
(2.56)
(2.20)
(2.13)
(0-10)
Q3
(0-10)
The only significant effect for explicit attitudes indicated that participants perceived ‘fat’
differently in the three conditions (F(2, 52) = 4.69, P < .05). Follow-up tests indicated that
‘fat’ was perceived as more insulting in the celebrity condition compared with baseline (t(27)
= -3.217, P < .01). Females reported a stronger belief that obesity is controllable (t(81.33) =
3.67, P <. 01) and perceived the word ‘fat’ as more insulting (t(55.85) = -3.27, P <. 01) than
males. No other sex differences emerged (see Table 6.2).
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Table 6.2: Means and standard deviations of explicit and implicit measures of perceptions of
obesity in relation to sex
Variable (range)
Baseline
Celebrity
Public
Male
Female
Male
Female
Male
Female
IAT
0.77
0.56
0.84
0.79
0.86
0.64
(D score)
(.59)
(.37)
(.44)
(.33)
(.35)
(.43)
ATOP
61.06
60.73
59.24
58.91
58.06
61.27
(0-120)
(13.28)
(13.07)
(17.47)
(16.92)
(18.61)
(14.41)
BAOP
13.24
10.36
14.18
10.27
14.76
9.64
(0-48)
(4.68)
(3.67)
(5.40)
(3.52)
(8.33)
(4.06)
AFAS
17.12
17.91
17.41
18.73
17.41
18.18
(5-25)
(3.59)
(3.27)
(3.62)
(3.10)
(4.00)
(2.27)
F-scale
3.91
4.23
3.89
4.12
3.94
4.08
(1-5)
(0.44)
(0.46)
(0.52)
(0.44)
(0.47)
(0.48)
Q2
7.12
8.18
7.59
8.82
7.47
8.18
(0-10)
(0.99)
(1.83)
(1.23)
(1.17)
(1.23)
(1.47)
Q3
6.53
6.45
7.24
5.73
7.47
6.55
(0-10)
(2.58)
(2.66)
(1.82)
(2.49)
(1.74)
(2.62)
6.4 Discussion
The aim of this study was to examine whether implicit and explicit anti-fat attitudes can be
reduced through a counter conditioning intervention. The study also aimed to compare the
effects of exposure to images of overweight and obese celebrities and the general public.
Results demonstrated that exposure to images of overweight and obese celebrities and the
public did alter anti-fat attitudes; however, in the majority of cases, perceptions became more
negative. Implicit data revealed greater IAT D scores for both of the experimental conditions
in comparison with baseline. Interestingly, although there was no significant difference
observed between IAT D scores in the three conditions, participants did respond significantly
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quicker when associating fat with unpleasant and thin with pleasant in the experimental
conditions compared with baseline. A slower association was also observed when associating
fat with pleasant and thin with unpleasant in the experimental conditions in comparison to
baseline, suggesting that the exposure to images of overweight and obese individuals,
irrespective of status affects implicit attitudes about obesity.
Explicit data revealed that participants perceived the word ‘fat’ as significantly more
insulting in the celebrity condition as opposed to baseline and perceived the word ‘obese’ as
significantly more insulting in the public compared with the celebrity condition. However, no
other effects were observed for explicit attitudes.
If the Elaboration Likelihood Model (Petty & Cacioppo, 1986) of persuasion and attitude
change is to be accepted, then the lack of change observed in implicit and the majority of
explicit responses would suggest that these attitudes have been formed through the central
route of processing, where processing is more complex and attitudes are less likely to be
shaped as a result of underlying messages. In this case the negative attitudes evident at
baseline were still evident after both experimental conditions and in some cases intensified
(although not significantly), irrespective of the positive messages accompanying the
presented images of overweight and obese individuals. If perceptions of obesity were
processed through the peripheral route, then these messages of overweight and obese
individuals as attractive, strong and credible, may have impacted these attitudes and
potentially reduced negative perceptions reported at baseline. Attitudes processed through the
peripheral route are less stable and can be altered by superficial cues that accompany a
message such as the attractiveness of an individual (O’Brien et al., 2010) thus it would be
rationale to expect the status of the celebrity to have affected these attitudes.
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Contrary to the hypothesis, exposure to positive images of the obese did not result in more
positive perceptions; hence, central and not peripheral processing may be involved in forming
attitudes towards the overweight and obese. Both implicit and explicit attitudes showed little
change, or indeed reinforced existing anti-fat attitudes, thus endorsing this suggested role of
central processing. Effective attitude shaping is, however, dependent on the strength of the
underlying message which can be increased by length of exposure to provide adequate
duration to scrutinise the persuasive message (Hague & White, 2005) therefore longer
exposure to the counter conditioning manipulation may have yielded results more in line with
expectations. Additionally, motivation is key to attitude change and which route of
processing is employed (Petty & Cacioppo, 1986). Participants’ motivation to alter their
attitudes was not assessed in this study, but may help to explain why no change in attitude
was observed. Future research should measure motivation to change anti-fat attitudes and
where motivation is low employ a manipulation strategy.
In comparison to previous anti-fat attitude intervention research, the majority which have
reported a positive overall effect of reducing anti-fat attitudes have been based on explicit
findings. Only two studies have shown any promise in changing implicit anti-fat attitudes,
where Teachman et al. (2003) reported that participants with a BMI of greater than 25kg/m2
reported reduced implicit anti-fat attitudes after an empathy evoking intervention. Similarly,
O’Brien et al. (2010) reported that implicit anti-fat attitudes decreased when obesity was
attributed to genetic or environmental causes. The only other study that has reported an
increase in anti-fat attitudes was by Hennings, Hilbert, Thomas, Siegfried, and Rief (2008)
who exposed participants to an educational film depicting overweight adolescents who
discussed negative experiences such as bullying as a result of their weight. The present study
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ANTI-FAT ATTITUDE INTERVENTION
therefore lends support for this previous finding that exposure to overweight and obese
individuals can increase anti-fat attitudes and together present a concerning occurrence.
In comparison to previous research that has used a counter conditioning technique, such as
that by Litcher and Johnson (1969) whose intervention was based over four months, in the
present study exposure to the counter conditioning procedure was of a comparatively short
duration. This may have accounted for the disparity in findings as these authors report a
positive effect for their intervention. Nevertheless it is worth acknowledging that irrespective
of the shorter duration of the intervention than in previous studies, the worsening of
perceptions as a result of the experimental conditions is intriguing and warrants further
examination to gain a more comprehensive appreciation of the effects of overweight and
obese images on attitudes. This worsening of anti-fat attitudes was similarly not reported in
the two studies that have previously examined a counter conditioning intervention for anti-fat
attitudes. A potential reason for this difference is that the previous studies employed an
intervention that evokes empathy in addition to counter conditioning. Moreover, Wiese et al.
(1992) were unable to determine whether a change in controllability beliefs was due to
evoking empathy or counter conditioning and the findings of Gapinski et al. (2006) may have
been confounded by testing participants in groups and therefore producing a social
desirability effect rather than a change in attitude.
The current study results also contradict those of Dasgupta and Greenwald (2001) who
showed reduced bias towards a stigmatised group using counter conditioning. Whereas
Dasgupta and Greenwald reported a reduction in implicit white preference, a greater thin
preference or anti-fat response was observed in the present study. Although both racial and
weight bias in society have been well established (e.g., Puhl & Brownell, 2005), it seems that
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the two should be viewed as substantially different. Racial prejudice has received a
considerable amount of attention and exhibiting racial prejudice is generally frowned upon in
contemporary society. In contrast, although weight discrimination is increasingly
acknowledged, being prejudiced about people’s weight may be viewed differently in
comparison with other stigmatised attributes such as sex or race. This presents an
increasingly difficult task in attempting to intervene with anti-fat attitudes.
One reason that race and weight bias may be viewed differently is controllability, as race is
inherent and therefore individuals do not control their race, whereas weight is perceived by
some as at least under partial control of the individual (Teachman et al., 2003), which
provides a basis for judgements to be made. Obesity is therefore perceived as a moral
transgression and evidence of a lack of control which is further reinforced by the media
(Saguy & Riley, 2005) as demonstrated in study 2. Furthermore, there appears to be no
deterrent to forbid anti-fat attitudes whereas there is for other attitudes (e.g., racial attitudes),
which is concerning given the link between anti-fat attitudes and anti-fat behaviours (O’Brien
et al., 2008). For instance, discrimination laws exist against racism, but no such legislation
currently exists in the UK in relation to obesity, unlike race and sex (The Equality Act, 2010).
Hence, it may be that anti-fat attitudes are perceived as more ‘acceptable’, making them more
resistant to change irrespective of factors such as status that help to facilitate change in other
attitudes. Research that explores this suggestion and the factors that contribute to the
development of anti-fat attitudes would therefore seem important.
The current study findings are of significance and add to the limited literature to suggest that
images of overweight and obese individuals may have a detrimental effect on obesity
perceptions. Previously, McClure et al. (2011) reported that fat phobia became more negative
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as a result of exposure to stereotypical images of the obese accompanying news stories
compared with exposure to non-stereotypical images or when no image was presented
(baseline). However, the current study results suggest that exposure to positive images of the
obese may increase negative perceptions of these individuals. The present study finding that
exposure to public images of overweight and obese individuals has a minimal, or indeed a
negative effect on anti-fat attitudes, to some extent supports the previous findings of Swami
et al. (2008) who reported that stigmatisation and assigning the characteristics lonely, lazy
and teased to the overweight increased when individuals were exposed to photographs of
overweight individuals. Swami and colleagues suggest that this occurrence is not surprising,
where the larger the discrepancy a body size is from the perceived societal ideal of physical
attractiveness the greater stigmatisation and stereotyping is likely to be.
Moreover, exposure to images of overweight and obese individuals may increase anti-fat
attitudes, irrespective of the individual’s status. All images used in the present study were
positive and non-stereotypical, for example, some of the images used in the public condition
were of doctors or fitness instructors and therefore this identifies a very problematic situation.
The public are exposed to images of overweight and obese public and celebrities everyday
whether in daily life or in the media. Thus, if through this everyday exposure anti-fat attitudes
are similarly heightened, this would shed some light on why prejudice and discrimination of
overweight and obese individuals has been documented in the past across different areas of
life such as in the work place or at school (Puhl & Brownell, 2001). Future studies are
required to examine anti-fat attitudes in more ecologically valid contexts to tease out the
effect of everyday exposure.
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ANTI-FAT ATTITUDE INTERVENTION
Despite the ineffectiveness of the anti-fat attitude intervention, this study does have its
strengths. Firstly, it is the first study to examine counter conditioning independently as an
intervention to reduce anti-fat attitudes, where those previously (Gapinski et al., 2006; Wiese
et al. 1992) have used designs that present confounds, thus it cannot be concluded if
inconclusive counter conditioning has an effect. Secondly, whilst the present study supports
Gapinski et al. (2006) in reporting that counter conditioning is ineffective in reducing anti-fat
attitudes, it does however highlight a major implication that has not been reported previously,
in that the findings suggest exposure to overweight and obese images maintains and
potentially exacerbates anti-fat attitudes. Thirdly, this study uses both implicit and explicit
measurement, which is an important inclusion as research (e.g., Bessenoff & Sherman, 2002)
has demonstrated that implicit and explicit attitudes are distinctly different and predict
different behaviours. Thus research should measure both types of attitude, an omission of
some of the previous attempts to change anti-fat attitudes (e.g., Diedrichs & Barlow, 2011).
This study also answers the call for research that examines potential anti-fat attitude
interventions (Danίelsdόttir et al., 2010; O’Brien et al., 2010; Puhl & Brownell, 2005), that is
imperative given the widespread prevalence of anti-fat attitudes as demonstrated in previous
research (e.g., Puhl & Brownell, 2001) and in study 1, in addition to the relationship recently
established with anti-fat behaviours (O’Brien et al., 2010) and reports of discrimination in a
number of contexts such as work and school.
A potential limitation of this study was that the celebrity images were accompanied by a short
description, which makes it impossible to decipher whether the effects observed for that
condition are a consequence of the images, the descriptions or both. Additionally, as a result
of the extra information accompanying the celebrity images, this will have affected the
amount of time participants were exposed to the images in comparison to the public
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ANTI-FAT ATTITUDE INTERVENTION
condition. Similarly in the public condition, participants viewed the slideshow twice and only
once in the celebrity condition. However, as there was little difference between celebrity and
public conditions this difference in stimulus exposure is likely to have had a minimal effect
on results. Another limitation was the relatively short duration of exposure to the images of
overweight and obese populations in comparison to previous uses of counter conditioning to
modify other attitudes (e.g., Litcher & Johnson, 1969), thus, a longer duration of exposure to
the counter conditioning intervention may have increased the likelihood of participants
receiving the underlying message. A potential third limitation of this study was that although
celebrities may be perceived positively, this may not be enough to endorse a message to an
audience, as Petty and Wegener (1999) suggest that a celebrity is more likely to have an
effect on those exposed to the message if they are perceived to be relevant to the message.
Thus, the descriptions used in the celebrity condition may have detracted from the main
message of reducing anti-fat attitudes where participants’ attention may have been focused on
the achievements of the celebrity as opposed to their body shape.
Future research should examine whether perceptions of overweight and obese images differ
depending on the sex of the individual portrayed, as previous research (e.g., Puhl &
Brownell, 2006) has reported that obese women report being stigmatised by the general
community more than obese men. Future work should also examine the potential differences
in stigmatisation towards obesity and other characteristics that are stigmatised such as race
and sex. This would provide valuable information as to why the obese are openly
discriminated against and whether interventions designed to alter attitudes towards other
characteristics such as sex may be appropriate for modifying anti-fat attitudes. Another future
research avenue worth exploring is a comparison of the impact of visual and written accounts
about overweight and obesity on attitudes and beliefs as the current study used both forms of
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ANTI-FAT ATTITUDE INTERVENTION
information in the celebrity condition making it impossible to differentiate between them.
Finally, future research should also examine whether the effectiveness of counter
conditioning as an anti-fat attitude intervention is weight specific. Previously, Robinson et al.
(1993) demonstrated that counter conditioning was effective in reducing fat phobia with a
sample mainly comprised of overweight or obese treatment seeking women (89%). Robinson
et al’s (1993) study can be perceived as an intervention to reduce self decrement and
therefore the present study may similarly have obtained a greater effect using a sample of
overweight or obese participants instead of the mainly average weight sample employed.
Thus with participants who report system justifying attitudes (i.e., overweight and obese
individuals who report anti-fat attitudes) counter conditioning may be an effective tool for
reducing self decrement and increasing self affirmation. However, with underweight and
average weight participants, counter conditioning may prove ineffective for modifying antifat attitudes given the constant messages individuals are exposed to daily that indicate excess
fatness is negative and that one should strive to achieve the “perfect body” (Markula, 2001).
This study sought to provide insight into a potential intervention to change anti-fat attitudes.
With the limited amount of previous research aimed at reducing implicit and explicit anti-fat
attitudes (O’Brien et al., 2010) and the present study findings demonstrating the potential for
everyday images to maintain or even increase anti-fat attitudes, future research is clearly
warranted that examines other interventions that may be effective and other sources that
influence and potentially increase anti-fat attitudes. Contrary to the initial aim and
expectations results have shown that through exposure to positive images of overweight and
obese individuals anti-fat attitudes may become more negative. However, results have also
demonstrated that participants have negative implicit and explicit anti-fat attitudes in
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ANTI-FAT ATTITUDE INTERVENTION
accordance with previous research (e.g., Crandall, 1994; Gapinski et al., 2006) and the
findings of study one.
The main implication of the findings is that exposure to positive images of overweight and
obese populations may intensify and more certainly seems to maintain anti-fat attitudes.
Consequently, if this effect is replicated, coverage of overweight and obese populations in the
media may have an adverse effect on perceptions of obesity, irrespective of the light in which
the coverage is intended. Thus, teasing out this relationship appears paramount to developing
a more comprehensive understanding of the typical behaviours directed towards overweight
and obese individuals and responses to direct and indirect contact with overweight and obese
individuals.
6.5 Conclusion
The current study provides valuable insight into the effects of exposure to positive images of
overweight and obese people on anti-fat attitudes and how they may be maintained and
possibly exacerbated as a result. Evidently, given the current study findings and the mixed
effectiveness of other interventions in modifying anti-fat attitudes this area of research
requires further attention and appears particularly complex. For other stigmatised
characteristics or disabilities (e.g., race, sex) prejudice and discrimination has been seen and
dealt with and legislation exists to deter individuals from engagement in such behaviour.
However, there appears to be little in the way of protection for overweight and obese
individuals from such negative experiences; indeed negative portrayals and fat jokes are
common in the media (Puhl and Brownell, 2001; Study two results). Thus it would appear
that prejudice and discrimination are instead encouraged and openly accepted in comparison
to other stigmatised conditions.
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This study highlights a need to examine influential sources that contribute to the formation of
anti-fat attitudes and why they appear to be so robust. Furthermore, the paucity and limited
effectiveness of attempts to reduce anti-fat attitudes call for future research into attitude
modification interventions. This research should endeavour to overcome the obstacle of
robust attitudes by ensuring that interventions allow individuals to diligently consider
information included and experience repeated exposure to increase the likelihood of central
as opposed to peripheral route processing.
221