Fat Phobia and the F-Scale-Measuring, Understanding and Changing Anti-Fat Attitudes Melpomene Journal, 03-01-1997 Author Note In 1985, Judy Mahle Lutter, president of Melpomene Institute, and I (Bean Robinson) discussed our mutual interest in what I was just starting to call "fat phobia," the fear and dislike of fatness often manifested as negative attitudes and stereotypes about fat people. I told Judy about a new scale I was thinking of developing to measure fat phobia, and she encouraged me to write an article about some of my work for the Melpomene Journal. It was after I said yes and began to write the article for the Melpomene Journal that I decided to complete my Fat Phobia Scale (F-Scale) and use Melpomene members as the first subjects to test my new scale. The newly completed Fat Phobia Scale was appended to the end of my article titled "The Stigma of Obesity: Fat Fallacies Debunked, " and Melpomene members were asked (begged) to complete the scale and return it to me for my research. Seventy-nine Melpomene members returned their completed surveys, and my research on this topic was up and running. I went on to collect more than 1,000 additional F-Scales and have written several articles and monographs on this topic. Introduction We seldom hear positive connotations of fatness as are implied in such statements as "Ye shall eat the fat of the land" (Genesis, XIV, 18) and "that people laughed and grew fat" (Woodman, 1980, p. 7). The existence of prejudice against fat people in the general population has been documented and summarized. Studies have shown that negative attitudes toward fat people are also prevalent among health and mental health professionals, including doctors and medical students, nurses and nursing students, nutritionists and psychologists. Fat Phobia Defined In this article, the term fat phobia refers to a pathological fear of fatness often manifested as negative attitudes toward and stereotypes about fat people. Our use of the term derives from popular usage and is modeled on Money's (1986) description of the term homophobia, which is defined as "a pathological fear of homosexualism" (from Greek, homos, meaning same, and phobias, meaning fear). Similarly, we use the term fat phobia to mean a pathological fear of fatness (from Greek faettra, meaning large vessel, and phobias, meaning fear).[1] Attribution of Blame Fat phobia may be stronger when people believe that fat people are responsible for their own obesity. This perception of responsibility can affect whether the fat person is liked or disliked. In one study, DeJong (1980) demonstrated that when high school girls were told that the fat subject was fat as a result of a thyroid problem, she was liked almost as much as an average weight subject and was liked significantly more than the fat subject without a thyroid problem. As a consequence of these and other findings, a few programs have been developed that attempt to educate fat clients about the complexity of weight and dieting and to increase their self-esteem and self-acceptance (Boyd, 1989; Polivy & Herman, 1992; Robinson, 1985; Robinson & Bacon, 1989). These programs attempt to relieve the fat clients of responsibility for their fatness by informing them about the genetic and metabolic factors contributing to obesity, the relative ineffectiveness of dieting and the evidence that fat people may not eat any more than thinner people (Harris, 1983; Harris et al., 1990). For a review of the newer research debunking some of these commonly held but inaccurate beliefs about fat people, see the Melpomene Journal article (Robinson, 1985) and Robinson, Gjerdingen, & Houge (1995). Goals Given the fact that many people, including fat people themselves, have negative attitudes toward fat people, it is important to discover if these attitudes can be changed and to explore what might contribute to such a change. To address this question, it is necessary to have a valid and reliable way of measuring attitudes toward fat people. Study 1 describes the development of a new scale in which adjectives selected represent common beliefs about fat people. Reliability and validity figures for this scale are reported. In addition, we hypothesized that the sociodemographic factors of Body Mass Index (BMI), age, sex, education and occupation would be related to differing attitudes toward fat people. Study 2 used this new scale to measure attitudes of fat women who had negative feelings about their bodies. We hypothesized that if fat women were given information that indicated they were not to blame for being fat, they would develop more positive attitudes toward fat people in general and themselves in particular. Study 1 Method Subjects. Data were collected from 1,135 subjects; 974 (89%) were females and 117 (11%) were males; their mean height was 65 inches and 71 inches, respectively; and their mean weight was 144 pounds and 178 pounds, respectively. BMI was 24.1 for females and 24.8 for males. The majority of subjects (68% of the females, N = 664; and 75% of the males, N = 87) had BMIs in the "acceptable" range, with approximately 9% of the subjects falling into each of the groups labeled "overweight" (N = 92 females and 11 males) and "severely overweight" (N = 89 females and 10 males). Approximately 9% (N-90) of the females and 7% (N = 8) of the males were "underweight." An additional .6% (N = 6) of the females but no males were classified as "morbidly obese" (Rowland, 1989).[2] Mean age was 33 years, with an age range of 12 to 77 years. Mean years of education was 15.9, with 90% (N = 961) of the subjects having more than a high school education. Subjects were professionals in the mental health and medical fields (31%, N = 328), professionals in other fields (18%, N = 187), nonprofessionals (13%, N = 140), homemakers (6%, N = 621 and students (31%, N = 327). The 1,135 subjects were recruited from a number of settings in the St. Paul-Minneapolis metropolitan area: 512 subjects attended a lecture or workshop on body image, 422 were college students, 81 were psychotherapy clients with negative body image and 41 were members of weight loss groups. An additional 79 people responded to a questionnaire in an article on fat phobia published in the Melpomene Journal (Robinson, 1985). All subjects participated voluntarily and without compensation.[3] Measure: The Fat Phobia Scale measures a person's attitudes toward fat people. This scale was developed in 1984 by the principal author who asked people entering a motor vehicle license bureau in a suburb of the St. Paul-Minneapolis metropolitan area to list adjectives describing people who are fat. Using a combination of these adjectives and clinical experience, a 50-item scale was constructed that is scored by adding the values for all 50 items. Total scores on the scale are converted to the original 5-point scale (1-5), where lower numbers indicate less fat phobia and higher numbers indicate more fat phobia. Table 1 Six-Factor Analytic Structure of the Fat Phobia Scale Factor 1 Undisciplined/Inactive/Unappealing poor self-control no will power overeats likes food self-indulgent unattractive shapeless inactive lazy unambitious slow disgusting careless having no endurance Factor 2 Jolly/Friendly good-natured easy to talk to humorous/funny warm tries to please people considerate of others friendly easygoing selfless good Factor 3 Poor Hygiene smells bad sweaty dirty does not attend to own appearance sloppy bad complexion pitiful Factor 4 Passivity not individualistic dependent passive nonassertive insignificant indirect ineffective inefficient weak unpopular Factor 5 Emotional/Psychological Problems insecure depressed low self-esteem miserable moody Factor 6 Smart/Creative artistic creative smart reads a lot Results Table 1 displays the factor structure of the Pat Phobia Scale using a principal components analysis with a varimax rotation. The following subscales identify six components of fat phobia: Undisciplined, Inactive and Unappealing; Jolly/Friendly; Poor Hygiene; Passivity; Emotional/Psychological Problems; and Smart/Creative. Mean scores for each of the subscales indicate that respondents tend to stereotype obese people as Undisciplined, Inactive and Unappealing (Factor 1) and as having Emotional and Psychological Problems (Factor 5). They do not seem to have strong stereotypes about fat people being Grouchy and Unfriendly (Factor 2); having Poor Hygiene (Factor 3); being Passive (Factor 4) or being Stupid and Uncreative (Factor 6). One-way analyses of variance and Tukey-B multiple comparison tests were performed on fat phobia scores and revealed significant effects for all five sociodemographic variables (Table 2). Degree of fat phobia is related to BMI (dr = 1, 1055; F = 8.2943; p = .0041), age (df = 1, 1002; F = 9.1116; p = .0026), sex (df = 1, 1089; F = 4.5996; p = .0322), education (dr = 1, 1133; F = 6.8336; p = .0091) and occupation (dr = 4, 1134; F = 3.6159; p = .0062). Respondents who: (1) were average or underweight were more likely to have fat phobic attitudes than those who were overweight; (2) were younger [less than 55 years) were more likely to have fat phobic attitudes than those who were older than 55 years, Table 2 Means and Standard Deviations for Fat Phobia Scale and Subscales M SD Factor 1 Undisciplined/inactive/unappealing 3.6 .54 Factor 2 Jolly/friendly 2.5 .52 Factor 3 Poor hygiene 3.1 .55 Factor 4 Passivity 3.1 .48 Factor 5 Emotional/psychological problems 3.5 .64 Factor 6 Smart/creative 2.8 .52 Total Score 3.1 .38 Note: All items are scored using a 5-point semantic differential scale where lower numbers indicate less fat phobia and higher numbers indicate more fat phobia. Total scores on the scale are converted to the same 5-point scale (1-5) where lower numbers indicate less fat phobia and higher numbers indicate more fat phobia. (3) were female were more likely to have fat phobic attitudes than those who were male; (4) had more than a high school education were more likely to have fat phobic attitudes than those who had a high school education or less; (5) were nonmedical professionals were more likely to have fat phobic attitudes than students. Study 2 Method Subjects. The subjects, a subset of the 1,135 people from Study 1, were 40 Caucasian women who participated in a Self-Esteem/Body Image program at a mental health clinic in a suburb of the St. Paul-Minneapolis metropolitan area between 1983 and 1991. A total of 50 women were treated in individual, family and group settings. Seven groups were conducted, ranging in size from five to 13 members. Complete pretest and posttest data on the Fat Phobia Scale were collected from 40 of these participants (a response rate of 80%); 10 participants (20%) either did not complete the program or did not complete the posttest. The mean age of the subjects was 40 years; mean height was 65 inches, mean weight was 205 pounds, and mean BMI was 34. Half of the subjects (N = 19) had BMIs in the severely overweight category, 29% (N = 11) in the overweight category, 13% (N = 5) in the acceptable range and 8% (N = 3) in the morbidly obese category (see Footnote 2). The mean number of years of education was 13.6 years, with 68% (N = 27) having more than a high school education. Subjects were professionals employed in the fields of mental health or medicine (10%, N = 4), professionals in other fields (15%, N = 6), nonprofessionals (50%, N = 20), and homemakers (25%, N = 10). During interviews prior to treatment, all of the women reported that they had negative feelings about their body size and/or shape that produced subjective distress and caused them to restrict their activities. Procedures. Subjects completed the Fat Phobia Scale before taking part in the Self-Esteem/Body Image program. The content and format of this program was developed by the authors of this article, who based their ideas on the work of Susan and Wayne Wooley (Dyrenforth et al., 1980; Wooley & Wooley, 1979; Wooley & Wooley, 1980; Wooley et al., 1979a, Wooley et al., 1979b). The authors were also the co-therapists of the group. Clients were seen in individual sessions (two to five sessions) and in two-hour group sessions (eight to 12 sessions). Several strategies were used to increase positive perceptions about fat people and to raise clients' self-esteem, including: (a) reducing blame by presenting evidence that one's weight is largely determined by factors outside one's control; (b) broadening standards of beauty and attractive body size by presenting magazines, books, experiential exercises and other materials focusing on the physical beauty of fat people; (c) minimizing the perceived disability associated with being fat and encouraging behavior change in restricted areas (Robinson & Bacon, 1989[4]); (d) presenting information about the discrimination and prejudice fat people face and encouraging assertiveness, political activism and consumer pressure techniques to counter this prejudice. At the end of the last group session, the subjects again completed the Fat Phobia Scale. Results Results show that 60% of the clients decreased their level of fat phobia on the Fat Phobia Scale (F-Scale) after they participated in the Self-Esteem/Body Image program. More specifically, 25% showed substantial improvement, 35% showed improvement, and 40% showed no change on the Fat Phobia Scale. None of the participants was more fat phobic after her participation in the program. Conclusions and Discussion Results from this first analysis of the Fat Phobia Scale are encouraging with regard to its reliability, validity and factor structure. Internal consistency for the total scale, as well as for the six subscales identified by factor analysis, meets criteria which are commonly cited in the literature (Nunnally, 1978).[5] Construct validity is suggested by the findings of this study demonstrating that fat phobia, as measured by the Fat Phobia Scale, decreases after an intervention designed to reduce fat phobia. Factor analysis yields six dimensions that are consistent with other concepts of fat phobia in the literature. Limitations Several weaknesses in study design need to be taken into account when drawing conclusions. First, the sample of 1,135 respondents in Study 1 consists primarily of college students or people interested enough in body image, weight control, eating disorders or obesity to either come to a lecture or read an article on the topic. Thus, respondents are more likely to be female, have a professional job and have more education than a representative sample of adults. Future research should use this measure among males and less educated respondents to see if the same relationships persist. Second, the lack of a control or comparison group in Study 2 and lack of information on the test-retest reliability of the Fat Phobia Scale means that any improvement in Fat Phobia scores cannot be clearly attributed to the intervention that group members received and may be due to other factors, including measurement error. Research examining the test-retest reliability of the scale and controlled studies of interventions designed to change fat phobic attitudes are necessary to prove that such attitudes can be altered and that the Fat Phobia Scale can measure such attitude change. Third, fat phobic attitudes were measured before and immediately after the therapeutic interventions. Future research should investigate how lasting such attitude changes are, given our cultural focus on thinness, and what types of relapse prevention strategies would be useful in maintaining more positive attitudes. Finally, this scale does not have validity indicators to control for the tendency of people to give socially desirable answers regardless of their true attitudes. Social psychological research suggests that when obvious and direct methods of assessing prejudice are used, both racial and gender prejudice seem to be practically extinct. When social desirability is controlled by using more subtle techniques, prejudice reappears (Myers, 1987). Thus, the Fat Phobia Scale may understate the prejudice that people have toward fat people since it is a fairly obvious measure. However, this may be less of a problem with regard to fat phobia because expressing fat phobic attitudes is still socially acceptable in many contexts. Stereotypes Our results confirm findings that stereotypical attitudes about fat people are more complex than many previous studies have suggested (Agell & Rothblum, 1991; Rothblum et al., 1988; Tiggemann & Rothblum, 1988). We found evidence of both positive and negative stereotypes about fat people. The most common negative stereotypes viewed fat people as undisciplined, inactive and unappealing (Factor 1), as evidenced by their ratings on items concerning how they like food and overeat, evidence poor self-control and lack will power and are shapeless and unattractive. Another common negative stereotype was that fat people have emotional and psychological problems (Factor 5), as evidenced by their ratings on items concerning their low self-esteem, insecurity and depression. Like Agell and Rothblum (1991) and Tiggemann and Rothblum (1988), we found that the most common positive stereotype was that fat people are not grouchy and unfriendly (Factor 2), as evidenced by their ratings on items concerning their friendliness, warmth and humor. When dealing with stereotypes about a group of people, however, the issue of what is a positive, as opposed to a negative, stereotype is unclear. In most situations, being described as good natured, easy to talk to, humorous, funny and warm is seen as a strength. However, this stereotype has not been welcomed by many fat people. Sociodemographic Variables Our results indicate that respondents who are average weight, female, younger (less than 55 years old) and have more than a high school education or are nonmedical professionals are more likely to have fat phobic attitudes than respondents who are overweight, male, older (at least 55 years old) and have no more than a high school degree or are currently college students. Our results confirm the Crandall and Biernat (1990) and Young and Powell (1985) findings that women are more fat phobic than men. This certainly fits with other research indicating that the stigmatization with regard to fatness appears to be worse for fat women than for fat men (Crandall & Biernat, 1990; Orbach, 1978; Wooley, et al., 1979a), causing many to describe fat as a women's issue. Our finding that respondents with a high school education or below were less fat phobic than respondents with more education needs to be confirmed by other studies. It fits with anecdotal reports of greater acceptance of overweight among lower socioeconomic and minority groups (Cash & Pruzinsky, 1990) but does not confirm the one other study that investigated this variable (Bagley et al., 1989). However, that study used a restricted educational range (i.e., nurses with a baccalaureate degree vs. nurses without a baccalaureate degree). Ours is the only study comparing medical professionals' attitudes toward fatness with those of people in other occupations. Our results confirm other studies documenting fat phobic attitudes among health and mental health professionals, but they also indicate that medical professionals do not appear to have more negative attitudes than the other professionals, nonprofessionals, students and homemakers studied here. Our findings add to the welter of often contradictory results in the literature regarding two sociodemographic correlates of fat phobic attitudes: body mass and age. The literature is mixed with regard to whether fatter or thinner people or older or younger people are more likely to have fat phobic attitudes. A meta-analytic study using similar analyses and cutoffs for age and BMI ranges, as well as controlling for the confounding effects of correlated variables (Friedman, 1987), would help sort the findings regarding these variables. Contradictory results may merely be due to the restricted age and weight ranges used in these studies, as well as to confounding variables. Further research should investigate additional correlates of fat phobic attitudes, such as political conservatism and authoritarianism (Crandall & Biernat, 1990) and their interaction with sociodemographic variables. Lowering Fat Phobia Our results in Study 2 indicate that the fat phobic attitudes of clients, as measured by the Fat Phobia Scale, improved after a multifaceted intervention designed to increase positive perceptions about fat people and to raise clients' self-esteem. This intervention strongly stressed removing blame from fat people for their fatness by educating them about the complex etiology of obesity and the difficulties of treatment. However, it is unclear from the design of this study which specific technique, or which combination of the techniques used, accounted for the improvement in fat phobic attitudes or, for that matter, whether our interventions were responsible for the change in attitudes. There is little in the literature examining techniques for changing fat phobic attitudes other than a study by Harris (1983) that found a weak correlation between knowledge about fatness and more positive attitudes toward fat people. Future research should investigate which of these and other techniques for reducing fat phobia are most effective. Social psychological research examining prejudice against racial minorities and women has demonstrated that overt prejudice is far less prevalent in America today than it was just 40 years ago (Myers, 1987). This change has been due at least in part to the various movements and organizations that fought discrimination against African Americans and women in legal, social and economic arenas. The success of such groups in changing societal attitudes bodes well for the efforts of similar groups working on behalf of fat people. In the meantime, we agree with Crandall and Biernat (1990), who suggest that fat phobia be used as the "venue for investigating stereotyping and prejudice more generally" because there appear to be few social sanctions "invoked against those who express anti-fat attitudes" (pp. 240-241). Beatrice "Bean" E. Robinson, Ph.D., is an assistant professor, Program in Human Sexuality, Department of Family Practice and Community Health, University of Minnesota Medical School, Minneapolis, Minnesota. Jane G. Bacon, M.A., is a psychologist, White Bear Lake Area Community Counseling Center, White Bear Lake, Minnesota. Preparation of this article was supported in part by resources and assistance from the Program in Human Sexuality, Department of Family Practice and Community Health, University of Minnesota Medical School; Wilder Research Center; and the White Bear Lake Area Community Counseling Center. J. (1993). Fat phobia: Measuring, understanding, and changing anti-fat attitudes. International Journal of Eating Disorders, Vol. 14 (4), 467-480. References Agell, G., & Rothblum, E.D. (1991). Effects of client's obesity and gender on the therapy judgments of psychologists. Professional Psychology: Research and Practice, 22, 223-229. Bagley, C.R., Conklin, D.N., Isherwood, R.T., Pechiulis, D.R., & Watson, L.A. (1989). Attitudes of nurses toward obesity and obese patients. Perceptual and Motor Skills, 68, 954. Boyd, M. A. (1989). Living with overweight. Perspectives in Psychiatric Care, 25 (3,4), 48-53. Cash, T.F., & Pruzinsky, T. (Eds.), (1990). Body images: Development, deviance, and change. New York: Guilford Press. Crandall, C., & Biernat, M. (1990). The ideology of anti-fat attitudes. Journal of Applied Social Psychology, 20, 227-243. DeJong W. (1980). The stigma of obesity: The consequences of naive assumptions concerning the causes of physical deviance. Journal of Health and Social Behavior, 21, 75-87. Dyrenforth, S.R., Wooley, O.W., & Wooley, S.C. (1980). A woman's body in a man's world: A review of findings on body image and weight control In J.R. Kaplan (Ed.), A woman's conflict: The special relationship between women and food (pp. 30-57). New Jersey: Prentice-Hall, Inc. Friedman, G.D. (1987). Primer of epidemiology (3rd ed.). New York: McGraw-Hill. Harris, M.B. (1983). Eating habits, restraint, knowledge and attitudes toward obesity. International Journal of Obesity, 7, 271-286. Harris, M.B., Waschull, S., & Walters, L. (1990). Feeling fat: Motivations, knowledge, and attitudes of overweight women and men. Psychological Reports, 67, 1191-1202. Hiller, D.V. (1981). The salience of overweight in personality characterization. Journal of Psychology, 108, 233-240. Money, J. (1986). Lovemaps. New York: Irvington. Myers, D.G. (1987). Social psychology (2nd ed.). New York: McGraw- Hill. Nunnally, J.C. (1978). Psychometric theory (2nd ed). New York: McGraw-Hill. Orbach, S. (1978). Fat is a feminist issue. New York: Berkley. Polivy, J., & Herman, C.P. (1992). Undieting: A program to help people stop dieting. International Journal of Eating Disorders, 11, 261-268. Robinson, B.E. (1985). The stigma of obesity: Fat fallacies debunked. The Melpomene Report: A Journal of Women's Health Research, 4(1), 9-13. Robinson, B. E., & Bacon, J.G. (1996). The "If only I were thin..." treatment program: Decreasing the stigmatizing effects of fatness. Professional Psychology: Research and Practice, 27(2), 175-183. Robinson, B.E., & Bacon, J.G. (1989). The self-esteem/body image program. (Available from the authors). Robinson, B.E., Gjerdingen, D.K., Houge, D. (1995). Obesity: A move from traditional to more patient-oriented management. Journal of the American Board of Family Practice, 8(2), 1-10. Robinson, B.E., & Bacon, J.G, & O'Reilly, J. (1993). Fat phobia: Measuring, understanding, and changing anti-fat attitudes. International Journal of Eating Disorders, Vol. 14(4), 467-480. Rothblum, E.D., Miller, C.T., & Garbutt, B. (1988). Stereotypes of obese female job applicants. International Journal of Eating Disorders, 7, 277-283. Rowland, M.L. (1989). A nomogram for computing body mass index. Dietetic Currents, 16(2), 1-12. Tiggemann, M., & Rothblum, E.D. (1988). Gender differences in social consequences of perceived overweight in the United States and Australia. Sex Roles, 18(1/2), 75-86. Woodman, M. (1980). The owl was the baker's daughter. Toronto: Inner City Books. Wooley, S.C., & Wooley, O.W. (1979). Obesity and women -- I. A closer look at the facts. Woman's Studies International Quarterly, 2, 69-79. Wooley, S.C., & Wooley, O.W. (1980). Eating disorders: Obesity and anorexia. In A. Brodsky & R. Hare-Mustin (Eds.), Women and psychotherapy: An assessment of research and practice (135-156). New York: Guilford Press. Wooley, O.W., Wooley, S.C., & Dyrenforth, S.R. (1979a). Obesity and women -- II. A neglected feminist topic. Woman's Studies International Quarterly, 2, 81-92. Wooley, S.C., Wooley, O.W., & Dyrenforth, S.R. (1979b). Theoretical, practical, and social issues in behavioral treatments of obesity. Journal of Applied Behavior Analysis, 12, 3-25. Young, L.M., & Powell, B. (1985). The effects of obesity on the clinical judgments of mental health professionals. Journal of Health and Social Behavior, 26, 233-246. Notes 1. The Greek word for fat has, from its origins, neutral connotations. The word obese (from Latin, meaning that which has eaten itself plump) assumes that eating makes people fat. The National Association for the Advancement of Fat Acceptance (NAAFA) champions the use of the more neutral word, fat, 2. These categories are based on Rowland's (1989) classification of BMI. Body Mass Index is calculated by dividing a person's weight in kilograms by the square of their height in meters (kg/m2). Regarding Rowland's use of the category "acceptable," we prefer a more neutral term. Furthermore, we feel the exclusion of a category such as "morbidly underweight" understates the health risks (e.g., anorexia) at the low end of the weight scale. 3. Information on 59 additional subjects was discarded because of incomplete data. 4. The REACT Scale (Robinson & Bacon, 1989) assesses the degree and extent to which people restrict their activities as a result of their body image concerns. Copies of this scale can be obtained by contacting the authors of this article. 5. Nunnally (1978) suggests that scale reliabilities of at least .70 will suffice for tests in the early stages of research. Ideally, the reliability ratio should approach .90. None of the scale scores falls below this .70 value, and the reliability of the total scale meets this ideal criterion of .90. Bacon, Jane G|Robinson, Beatrice "Bean" E, Fat Phobia and the F-Scale-Measuring, Understanding and Changing Anti-Fat Attitudes. Vol. 16, Contemporary Women's Issues Database, 03-01-1997, pp 24-.