Legal Evolution of a Law Against Weight Discrimination in the United States: A Focus on Massachusetts

Abstract

Weight discrimination heightens health inequalities, particularly among racial and ethnically diverse populations. We aim to research the legal evolution of the law against weight discrimination (S.2495) and raise awareness among lawmakers in the Commonwealth of Massachusetts. We invited officials (n = 199) to attend a legislative briefing, and 25.6% completed a 14-question anonymous survey upon arrival. Contrary to our hypothesis, this first-of-its-kind study found that most policymakers are aware of weight biases. While S.2495 did not pass, the current bill S.2669, prohibiting body size discrimination, has recently been reported favorably by the Joint Committee on the Judiciary and referred to the committee on Senate Ways and Means.

Introduction

Biases and discrimination against people with obesity lead to healthcare inequalities, social disparities, socioeconomic disadvantages, and psychological distress.^1–3 Obesity is the most common chronic disease among children and adults in the United States (US)^3,4; a 42.4% prevalence in adults and 18.5% in children continues to rise^1,3 Furthermore, racial and ethnic minorities have a higher prevalence of obesity and reduced treatment response to lifestyle, behavior, pharmacotherapy, and surgery.² Discrimination due to overweight and obesity may further exacerbate healthcare disparities and have harmful effects that subsequently impact these vulnerable populations.^2,5 Data from the National Survey of Midlife Development in the US suggests that discrimination rates due to weight/height have gone up in all age groups, but ages 65–74.⁶

There is a consistent relationship between socioeconomic status (SES) and body mass index (BMI) in developed countries depicted in the literature.⁵ The Council on Size and Weight Discrimination describes that a “wage penalty” exists for people who have overweight and obesity. ‘Workers heavier than average are paid $1.25/h less; over a 40-year career, they will earn up to $100,000 less before taxes than their thinner counterparts.⁷ Weight discrimination undermines individual and social prosperity and perpetuates SES inequalities.

Moreover, people with obesity are often targets of bullying starting in early childhood. A 15-year-longitudinal study by Puhl and colleagues found that weight-based teasing from peers and family during adolescence predicted obesity and adverse eating behaviors into adulthood.⁸ A large cross-sectional study reported unhealthy weight control behaviors by ethnicity: 67.3% Asian, 46.5% White, 44.8% Hispanic, and 43.1% Black girls.⁹ Impending interventions such as targeting weight discrimination may help to relieve psychological distress.

While discrimination is an intrinsic cultural issue that we cannot halt by law alone, legal protection will help increase awareness.¹⁰ Policies that adequately address discrimination should help reduce weight bias and stigma. This pilot study aims to examine the legal evolution of laws against weight discrimination, explore knowledge, and raise awareness among lawmakers in the Commonwealth of Massachusetts regarding weight-based discrimination’s repercussions on people with obesity. We hypothesize that the lack of legal prohibition of weight-based discrimination in the Commonwealth of Massachusetts is due to inadequate knowledge and awareness regarding this critical issue.¹¹

Materials and Methods

The Institutional Review Board (IRB) at Massachusetts General Hospital approved this research-to-policy study. We completed an in-depth evaluation of the legal evolution of laws against weight discrimination in the United States between March 2020 and December 2020. We searched articles in PubMed and Google Scholar utilizing keywords such as weight discrimination, weight laws, and weight bias. We included 15 sources for review. We obtained our last update in April 2022. Then, we utilized a survey to explore the knowledge and understanding of weight stigma and discrimination amongst policymakers in Massachusetts. We collected data in a de-identified format. Moreover, our researchers also advocated for passing the Massachusetts Senate Bill S. 2495, which focused on unlawful discrimination based on height and weight, by holding a legislative meeting at the Massachusetts State House.

199 House of Representatives and Senate members in Massachusetts via public records were identified. Senators, representatives, and their aides were contacted through electronic mail to attend a legislative briefing session to discuss anti-weight discrimination legislation in Massachusetts; a 14-question survey was sent to assess their knowledge before the legislative meeting (Table 1). Each survey question had five answer choices rated from 0 to 4 (0: Strongly Disagree, 1: Disagree, 2: Neither Agree or Disagree, 3: Agree, and 4: Strongly Agree). A descriptive analysis based on the survey responses was performed.

Table 1.

Survey to assess weight discrimination knowledge and awareness among lawmakers in the Commonwealth of Massachusetts.

Question #	N	Minimum	Maximum	Mean ± SD
1. In this country, most people believe that weight says something about the character of a person	51	1	4	3.08 ± .82
2. In this country, people tend to use weight to categorize people socially	48	1	4	3.23 ± .75
3. The use of weight to categorize people has a long history in the USA.	45	1	4	3.13 ± .82
4. The use of weight to categorize people is embedded in US society	50	1	4	3.08 ± .83
5. Those categorized because of their weight “can’t wish away” the social label given to them	44	0	4	1.18 ± .92
6. This society uses the label of weight to stereotype people living in larger bodies	51	1	4	3.18 ± .74
7. The stereotype of weight reduces the humanity of those who are its targets	48	1	4	3.06 ± .78
8. In the USA, the stereotype of weight evokes a punitive response towards those to whom it is attached	46	1	4	2.98 ± .73
9. In the USA, those targeted because of their weight have low social power and low interpersonal status	45	1	4	2.20 ± .76
10. In the USA, those targeted because of their weight suffer discrimination	51	2	4	3.24 ± .71
11. In the USA, those targeted because of their weight suffer exclusion	52	1	4	3.02 ± .87
12. In the USA, all people who weigh more are poor	49	0	3	.98 ± .78
13. In the USA, access to key resources is blocked for those targeted because of their weight	44	0	4	1.86 ± .91
14. Most people in the USA do not like fat people much	50	0	4	1.96 ± .89

SD: Standard Deviation.

0: Strongly Disagree, 1: Disagree, 2: Neither Agree or Disagree, 3: Agree, and 4: Strongly Agree.

A planned briefing was held at the Massachusetts State House on March 10^th, 2020, on the eve of the COVID-19 pandemic. Several organizations, such as MEDA (Multiservice Eating Disorders Association), STRIPED (Strategic Training Initiative for the Prevention of Eating Disorders), and NEDA (National Eating Disorders Association), presented the background history of discrimination based on weight and height and a review of the discrimination laws in the US.

Results

Legal evolution of Anti-weight Discrimination Laws

In the US, only the state of Michigan has an anti-weight discrimination law.^6,11 The Elliott Larsen Civil Rights Act of 1976 prohibits “discriminatory practices, policies, and customs in the exercise of those rights based upon religion, race, color, national origin, age, sex, height, weight, familial status, or marital status,”¹¹ and provided additional protection against discrimination based on weight, unlike in any other US state. In March 2013, the Utah legislature considered adding protection against height and weight discrimination in the workplace (HB132). Still, the bill failed due to a lack of consensus amongst lawmakers as there was incongruence on how to hold employers accountable.¹² Compared to 40 years prior, weight discrimination has become a much more urgent issue due to the increasing trends in perceived weight discrimination in the United States.⁶

Currently, three cities, San Francisco and Santa Cruz, California, and Binghamton, New York, explicitly include weight as a protected category. Moreover, while the District of Columbia, Urbana, Illinois, and Madison, Wisconsin have laws that do not include weight as a protected category, their rules protect against discrimination based on personal appearance. They also cover employment, housing, and business establishment categories.¹¹

Lately, several cases have been brought to courts throughout the US regarding weight discrimination. One such case was brought to court in Washington state in the summer of 2019. The Washington state Supreme Court, as a result, ruled that obesity is a disability under the Americans with Disabilities Act (ADA).¹³ In addition, in Florida, Senator Braynon recently proposed to revise the Florida Civil Rights Act of 1992 to include weight and height as two more discrimination categories. It was scheduled to be effective in July of 2020¹⁴ but did not go through.

Legislators’ Awareness of Weight Stigma and Discrimination Survey

51 (25.6%) participants (senators, representatives, and their aides) completed the survey before the legislative briefing. Each survey question had five choices: Strongly Disagree, Disagree, Neither Agree or Disagree, Agree, and Strongly Agree. The survey responses calculated a minimum, maximum, mean, and standard deviation (Table 1). Most participants agreed with statements that suggested awareness among the respondents, such as “… weight says something about the character of a person” or “… people tend to use weight to categorize people socially” or “… those targeted because of their weight suffer discrimination”. On the other hand, most respondents disagreed with misconceptions about obesity, such as those categorized because of their weight can’t wish away” the social label given to them” and “all people who weigh more are poor”. Thus, contrary to our initial hypothesis, most of our results pointed towards an awareness of weight discrimination.

Legislative Briefing

A legislative briefing was held in the presence of lawmakers, staffers, and many members of multiple organizations. The legislation meeting ensured that policymakers were well-informed and updated with general background and growing facts regarding the consequences of weight discrimination before deciding to pass S.2495 bill.

Massachusetts has considered anti-weight discrimination legislation for the past 15 years. The S. 2495 bill was introduced in 2007 to the Massachusetts state legislature by Byron Rushing.¹⁵ In February 2020, Senator Rausch (S.1012) and Representative Nguyen (H.3413) sponsored a bill to add weight as a protected category (S.2495); this received a favorable vote from the Judiciary Committee in February 2020. However, S.2495 did not pass in the state legislature due to a change of priorities affected by the current COVID-19 pandemic. On the other hand, efforts to pass a bill that prohibits body size discrimination have persisted. The current bill, S.2669, has been reported favorably by the Joint Committee on Judiciary on February 10, 2022, and referred to the committee on Senate Ways and Means.

Discussion

Obesity is a disease characterized by a high degree of stigma. Racial and ethnically diverse populations are the most at-risk groups for obesity and, consequently, weight discrimination. Past well-intended attempts to address obesity have led to stigmatizing stereotypes and possibly worse societal attitudes.^1,6 Awareness begins with citizens’ social involvement within their community and representatives. The perception that people with obesity are personally responsible for their weight gain has worsened a stereotype that blames the individual alone, without considering that obesity is a multifactorial disease and, therefore, should be managed by a multidisciplinary team.

While public health strategies to fight obesity at a societal level have been implemented, their long-term results are not evident. Indeed, efforts to address obesity through focused health policies at the national level, such as the Treat and Reduce Obesity Act (TROA), which seeks to expand Medicare coverage to cover evidence-based obesity treatment options, have continuously failed.¹⁰ In the meantime, weight discrimination continues to increase, probably counteracting the existing efforts. Therefore, further collaborative policy-to-effect endeavors, such as the one between health professionals and policymakers presented in this paper, are needed to strengthen efforts to educate the public and help build awareness of obesity as a disease and its complications.

Despite being considered in Massachusetts for over a decade, a law against weight discrimination has not yet passed. Current bill S.2669 prohibiting body size discrimination in Massachusetts was reported favorably in February 2022, which is reassuring. Our study is the first to investigate the evolution of law regarding weight discrimination and the knowledge of weight discrimination and bias against people with obesity among lawmakers in the Commonwealth of Massachusetts. The survey contained statements aimed to assess some known prejudices and stigma against people with obesity, and our results suggest awareness among Massachusetts legislative representatives. The Briefing provided updated background history about weight bias and discrimination along with a very informative review of the discrimination laws in the US. Assistants seemed satisfied, clarified doubts, and policymakers reacted positively to this approach.

This study has limitations, including its cross-sectional and subjective nature and a modest sample size despite outstanding efforts to reach a higher number of legislators. There were also limitations to determining the impact of our educational meetings on legislators due to Covid-19 restrictions, which were instituted immediately after the briefing. However, our data provide another rationale for why attaining legal protection against weight discrimination is crucial in the US. It highlights the difficulties of passing an obesity-focused policy. Our study targeted potential areas of opportunity with appropriate informative briefing sessions among the policymakers, yet the bill did not pass. COVID-19 pandemic may have blunted the passing of this bill. This study presents the opportunity for further research to elaborate on these findings.