Weight Bias: pervasive yet hidden harm of obesity

Introduction

Worldwide prevalence of obesity has been increasing at a menacing pace. As per WHO data, the incidence of obesity worldwide has tripled since 1975. As discussed in my post ‘Is obesity a disease or a risk factor for other conditions?’ in 2016 more than 1.9 billion adults, 18 years and older, were overweight; of these 650 million were obese. It has assumed epidemic proportions in children too. As discussed in my post ‘Childhood obesity: a serious public health challenge’, as per a study led by Imperial College of London and WHO, in a span of just 40 years, the number of school-age children and adolescents (5-19 years of age) with obesity has risen more than 10-fold from 11 million in 1975 to 124 million in 2016. Unfortunately, the obesity epidemic has been accompanied by a parallel epidemic of weight bias.

In my post ‘Complications of obesity: the mother of all diseases’, I had highlighted that obesity affects almost every aspect of health, from reproductive and respiratory function to memory and mood. Among the various psycho-social complications of obesity, I had discussed weight bias, which negatively affects not only psychological well-being but physical health as well. Although weight bias is pervasive in society and undermines people’s health extensively, awareness about it is very limited. In order to raise awareness about the prevalence, severity and diversity of weight stigma, the World Obesity Federation chose ‘End Weight Stigma’ as the theme for the World Obesity day 2018. To begin with, to help understand the topic better, the term weight bias and other related terms will be explained here briefly.

What is weight bias?

Weight bias is defined as negative attitudes towards, and beliefs about others, because of their weight. Weight bias can lead to:

• Prejudice – Preconceived negative judgments based on body size.
• Stereotypes – attitudes such as individuals with obesity are lazy, lacking in self-discipline, or lacking in will-power.

What is the weight stigma?

Weight bias can lead to weight stigma. Weight stigma refers to negative behaviours and attitudes that are directed towards individuals solely because of their weight. It involves actions against people with obesity that can cause exclusion and marginalization and lead to inequities.  It can take the form of teasing and verbal comments (e.g. name calling, being made fun of, and being humiliated in public), physical assaults and bullying (e.g. being spat on, hitting, kicking, pushing, shoving, having property stolen or damaged), relational victimization (e.g. social exclusion, being ignored or avoided, being the target of rumours), and overt discrimination (unfair treatment because of body weight, for example discrimination in healthcare, educational settings, and in the workplace, including hiring for job).

What is internalised weight bias?

What is it?

Internalised weight bias is defined as individuals’ belief that they deserve the stigma and discriminatory treatment they experience as a result of having overweight or obesity. So, people who internalise weight bias blame themselves for stigma and body weight. In other words, this is a form of self-stigma. People who internalize weight bias:

• Recognise that they have a socially devalued identity because of their weight.
• Attribute weight-based stereotypes to themselves.
• Engage in self-blame, self-criticism, and self-devaluation because of their body weight.

Who is affected?

Weight bias internalisation is seen more often in:

• Women compared to men
• People with higher body weight compared to lower body weight (but can be present across body sizes).
• White people tend to have higher levels of internalisation compared to other racial or ethnic groups.
• People who have experienced considerable weight-based stigma.
• People who are currently trying to lose weight.

What are the health consequences of internalized weight bias?

Internalised weight bias can contribute to the same health consequences as experienced weight bias, which will be discussed in subsequent sections. Though the impact of internalisation of weight bias on weight loss or weight gain is not really known, however, some studies have shown that internalisation of weight bias had an effect on weight loss and maintenance, while experienced weight stigma really didn’t play a role. These studies found that for every one-unit increase in internalised weight bias, the odds of maintaining weight loss decreased by 28%.

What is the prevalence of weight bias?

Weight bias is ubiquitous; it’s everywhere in our society today – from images in the media and jokes on television shows to comments from educators, healthcare professionals, employers, family and friends. Studies have shown that weight bias affects diverse groups of the population. Weight bias is experienced by both women and men; it is experienced throughout the lifespan – in childhood, adolescence and adulthood; and it is experienced in both low- and high-income and education groups. It is important to recognise that weight bias impacts across diverse weight categories; it is not limited to individuals with high levels of obesity – weight bias does occur in individuals at lower levels of overweight and at normal weight categories as well. This is the result of a weight-centric approach, in which weight is viewed as a proxy for health and beauty. Weight bias is also seen across multiple racial and ethnic groups and also in different countries. In brief, weight bias is a pervasive issue that many people are experiencing.

Are there any gender differences in the experience of weight bias?

Even though both men and women experience weight bias and stigma associated with overweight/obesity, women seem to experience higher levels of weight stigmatization than men, even at lower levels of excess weight. These gender differences may be on account of the feminine beauty ideal, which emphasises that “physical attractiveness is one of women’s most important asset, and something all women should strive to achieve and maintain.” Mass media, diet and fashion industry have heavily promoted thinness as being central to feminine beauty. As a result, thinness ideals have become deeply ingrained into our society and therefore women whose bodies do not conform to these physical beauty ideals may be vulnerable to weight bias. To make matters worse, women tend to internalise weight bias more than men and experience more unhealthy eating behaviours, including binge eating.

The extent of weight bias in different life domains.

Weight bias is common in many different life domains.

1. Weight bias in social relationships/family setting

Weight bias is commonly expressed in social relationships with friends and family members. A high percentage of overweight youth report being teased and victimised about their weight by family members. A study titled ‘Stigma, Obesity and the Health of the Nation’s Children’ published in ‘Psychological Bulletin’, journal of the American Psychological Association reported that 47% of very overweight girls and 34% of very overweight boys reported teasing by family members due to their weight. Of concern, and perhaps the most unexpected source of weight-based victimization towards youth with obesity is parents.

According to the Policy statement of the American Academy of Pediatrics, titled ‘Stigma Experienced by Children and Adolescents with Obesity’, published in the journal ‘Pediatrics’ of the American Academy of Pediatrics, in the year 2017, in a survey study of adolescents attending weight loss camps, 37% reported being teased or bullied about their weight by a parent. According to the statement, survey researchers who assessed experiences of weight stigma among women with obesity reported that family members were the most prevalent interpersonal source of weight stigma incidents, with 53% reporting weight stigma from their mothers and 44% reporting it from their fathers. Surprisingly, parents who were overweight/obese were just as likely to endorse negative stereotypes as thinner parents. Weight stigma expressed by parents can have a lasting effect on children and they may continue to suffer emotional consequences from these experiences through adulthood.

2. Weight bias in the educational setting

Research data consistently shows that children and adolescents with overweight/obesity are particularly vulnerable to weight bias from their peers. In a classic study performed in the late 1950s, titled ‘Cultural Uniformity in Reaction to Physical Disabilities’, published in the journal, ‘American Sociological Review’ in Apr 1961, 10 and 11 year old boys and girls, with and without physical handicaps and from diverse ethnic, social and cultural backgrounds were shown six images of children and asked to rank them in the order of which child they ‘liked best.’ The six images included a ‘normal’ weight child, an ‘obese’ child, a child in a wheelchair, one with crutches and a leg brace, one with a missing hand, and another with a facial disfigurement. Across six samples of varying social, economic, and racial/ethnic backgrounds from across the United States, the child with obesity was ranked last.

Given that peers are one of the most common sources of weight bias, it is not surprising that education setting, from nursery school through college, where children spend a major part of their time, is a common setting where weight bias occurs. In the school setting, weight-based bullying is among the most frequent forms of peer harassment reported by students.

The manifestation of weight stigma is not limited to older adolescents with severe levels of obesity; instead, research shows that negative attitudes towards overweight and obese peers emerge as young as 3 years olds. Children as young as preschoolers attribute negative characteristics and stereotypes to peers with larger body sizes. They feel that their overweight peers are mean and less desirable as playmates compared to the normal weight children. They also believe that overweight children are mean, stupid, ugly, unhappy, lazy and have few friends.

Among primary school children, these trends continue and in some cases worsen, with children reporting that overweight/obese peers are ugly, selfish, lazy, stupid, dishonest, having few friends and getting teased. In contrast, normal weight children are described as being clever, healthy, attractive, kind, happy, socially popular and a desirable playmate. As a consequence, to escape teasing and bullying, obese children miss more days of school compared to non-obese peers.

The weight stigma continues among adolescents with the same beliefs persisting; in addition, new stereotypes emerge. Studies have revealed that adolescents commonly stereotyped their overweight/obese peers as being lazy, unclean, eating too much, unable to perform certain physical activities (e.g. dancing), not having feelings, and in case of girls, unable to ‘get a boyfriend’. Similar findings have emerged in studies with college-age students.

Reports by students, educators, and parents all point to weight-based bullying as a significant problem in a school setting. Studies among racially diverse groups of adolescents indicate that weight-based harassment is the most prevalent form of harassment reported by girls and the second-most common form of harassment among boys. The likelihood of being a target for verbal, relational, and physical victimization from peers increases with an increase in BMI – children who have the highest weight are the most vulnerable to bullying. A study of adolescents seeking weight-loss treatment found that 71% reported being bullied about their weight in the past year, and more than one-third indicated that the bullying had persisted for more than 5 years.

Unfortunately, educators can be a source of weight stigma towards children and youth. In a study examining attitudes towards obesity among middle and high school teachers, one-fifth of the respondents reported beliefs that obese persons are untidy, less likely to succeed than are thinner persons, more emotional, and more likely to have family problems. Research also shows that teachers have lower expectations of students with obesity than they have of students without obesity, across a range of ability areas, including the expectation of inferior physical, social and academic abilities. Consequences of such negative attitudes on children and adolescents will be discussed in subsequent sections.

3. Weight bias in the healthcare setting

In the mid-80s the World health Organisation initiated the “Health Promotion” program considered as an essential strategy in achieving the general objective “Health for all” – health promotion of the population. The ideal model of healthcare was adopted in the declaration of the International Conference on Primary Healthcare held in Alma Ata, Kazakhstan in 1978 (known as the “Alma Ata Declaration). One of the five basic principles identified in the Alma Ata Declaration to achieve this goal is – Equitable distribution of health care. According to this principle, primary care and other services to meet the main health problems in a community must be provided equally to all individuals irrespective of their gender, age, caste, colour, urban/rural location and social class. One factor which has been missed in this declaration based on which patients should not be discriminate against, I strongly feel, is body weight. For healthcare providers, “do no harm” is a fundamental principle. In the above background, weight stigma in healthcare professional comes as more of a surprise.

Several decades of research has documented evidence of weight stigma in the medical setting. Many healthcare providers hold strong negative attitudes and stereotypes about people with obesity. In a research article titled ‘Implicit and Explicit Ant-Fat Bias among a Large Sample of Medical doctors by BMI, Race/Ethnicity and Gender’ published in the journal ‘PLOS ONE’, published by the Public Library of Science, in Nov 2012, a sample of 2284 physicians showed strong explicit and implicit anti-fat bias. In another article titled ‘Weight Bias in 2001 versus 2013: Contradictory Attitudes Among Obesity Researchers and Health Professionals published in the journal ‘Obesity’ in Jan 2015, researchers found that obesity specialists, consisting of researchers, clinicians, and other obesity-related professionals, held anti-fat/pro-thin implicit and explicit bias, and explicitly endorsed obesity-related stereotypes on traits of ‘lazy’, ‘stupid’, and ‘worthless’.

What is perhaps surprising is just how common these biases may be. In a study involving 2400 women with overweight and obesity, doctors were the second most common source of weight stigma reported by women. About 69% reported stigma from healthcare providers, and over half of women said that this had happened to them multiple times. 46% also reported weight stigma from nurses, 37% from dietitians, and 2% from mental health professionals. Unfortunately, weight bias appears to be present long before healthcare professionals enter clinical practice. A study of over 5800 first-year medical students from 49 medical schools in the US, showed that the majority of students expressed both explicit and implicit weight bias.

This stigma is even embedded in the way physicians talk about patients. In his book ‘The Secret Language of Doctors’, emergency physician Dr Brian Goldman analyses the coded lingo doctors use to describe difficult patients, situations and medical conditions. The lingo used in relation to overweight and obese patients revealed the stigma directed at overweight or clinically obese patients. Goldman, who hosts a CBC Radio program on medicine, witnessed doctors writing terms on patient’s charts like “three clinic units” to describe patients over 600 pounds, or “Chicago three plus” to describe someone over 300 pounds.

The evidence suggests that negative attitudes expressed by medical professionals are directed not just towards obesity as a health condition, but also against people who are obese. In an article titled  ‘Impact of weight bias and stigma on quality of care and outcomes for patients with obesity’, published in the journal Obesity Reviews, in Apr 2015, and based on a review of available research literature related to the impact of obesity stigma, reported many such stereotypes. According to the study, primary care providers, medical trainees, nurses and other healthcare professionals hold explicit as well as implicit negative opinions about people with obesity. Explicit attitudes are conscious and reflect a person’s opinions or beliefs about a group. However, people may not accurately report negative attitudes towards a group as social desirability may prevent some people from reporting anti-fat attitudes. Thus data on explicit attitudes may not reveal the true extent of the discrimination. On the other hand, implicit attitudes lie outside conscious awareness and occur automatically; thus implicit attitudes may predict prejudiced behaviours more effectively. Some of the implicit attitudes which are unconscious or spontaneous include behaviours such as decreased smiling and eye contact and increased spatial distance.

The common explicitly endorsed healthcare provider stereotypes about patients with obesity are that they are less likely to be adherent to treatment, are lazy, undisciplined and weak-willed. They report less respect for patients with obesity compared with those without; spend less time educating patients with obesity about their health and report them as a waste of time. Most importantly, physicians may over-attribute symptoms and problems to obesity. Patients with obesity often suffer dangerous delays in getting a proper diagnosis because doctors are so quick to blame any and all symptoms – from hip pain to shortness of breath  – on being overweight. As a result, they are more reluctant to perform preventive health screenings such as pelvic examination (despite the fact that higher-weight patients are at elevated risk for endometrial and ovarian cancer), cancer screenings, mammograms, and other diagnostic tests. Also, often they fail to consider treatment options beyond advising the patients to lose weight. In one study involving medical students, virtual patients with shortness of breath were more likely to receive lifestyle change recommendations if they were obese and more likely to receive medications to manage symptoms if they were normal weight. Additionally, patients with obesity have reported not being provided with appropriate-sized medical equipment such as blood pressure cuffs, patient gowns, chairs and doorways etc which results in a less welcoming clinical environment and affects the quality of the healthcare that is provided.

Anecdotal reports in the media suggest that patients have been denied care because of their obesity. Two such cases have been widely reported in the media in the recent past. In the first case reported in Apr 2018, Rebecca Hiles, 28 said she was told by doctors that her health problem was related to her weight; but it turns out that Hiles was suffering from cancer. “It was very scary to sort of exist in a body that I thought was failing me and have medical professionals who didn’t seem to take me seriously.” Hiles said on ‘Good Morning America.’ The headline on TV read ‘Misdiagnosed and body-shamed’ women says doctors blamed her weight and missed her cancer.

According to the report, at 17 years old, Rebecca Hiles came down with bronchitis and walking pneumonia (an informal term for pneumonia that isn’t severe enough to require bed rest or hospitalization). Three years later she was still coughing every day. Doctors said, “If you lost weight, you wouldn’t have this many coughing fits”, she recalls. One night she started coughing up blood, but when she went to emergency room, her doctors said it was probably just a broken blood vessel and sent her home with an inhaler. “That was the first time I started to think that maybe it wasn’t just weight”, she says.

By 23 years of age, the cough got so bad that Hiles began to have trouble controlling her bladder during coughing spasms and finally had to rely on adult diapers. The fits sometimes made her throw up. She spent many nights curled around a bucket in a hot shower, coughing and vomiting, hoping the steam would make it easier to breathe. When blood tests kept coming back normal, her doctors would say:

“We don’t know what to tell you –

it’s clearly just

weight-related.”

At the height of her coughing fits, Hiles, now 28, was taking so many medications that they couldn’t fit in a gallon-sized ziplock bag: cough syrups, antacids, steroids. “nothing was working”, she says. She began to wonder if she was a hypochondriac. Desperate for help of any kind, she researched in-patient mental health facilities. “I thought I was losing it.” Despite her steadily worsening coughing fits, her healthcare providers were still so fixated on her weight that they ignored symptoms that should have been worrisome in any active young women. Instead of listening to a patient when they say, ‘Well, I’m trying to work out, but then I can’t breathe,’ she explains, they just dismiss them by saying, ‘Well, if you lose a little bit more weight, it’s going to be easier for you to breathe.’

When another bloody coughing fit landed her in the emergency room, this time, the doctors did a more powerful CT-scan, rather than an X-ray, and found a tumour in her bronchial tube. “It was the first time in my life that I remember having a doctor take me seriously”, Hiles said.  The first moment that I saw my surgeon who said, ‘you have carcinoid cancer’ and the time that I had to surgery was two weeks. Carcinoid tumours are a type of slow-growing cancer that can arise in several places throughout your body. Less than two weeks later, she had surgery to remove her entire lung, the bottom half of which was a black, rotting piece of dead tissue. When my surgeon told me a diagnosis five years prior could have saved my lung, I remember a feeling of complete utter rage. Because “I remembered the five years I spent looking for some kind of reason why I was always coughing, always sick”, Hiles wrote on her blog. “Most of all, I remembered being consistently told that the reason I was sick was because I was fat.”

In another moving story, Ellen Maud Bennet, 64 used her obituary to advocate against fat shaming in the medical profession. She died on 11^th May 2018, after being diagnosed with inoperable cancer and being given only days to live. In her obituary, Ellen said, she had one final message about the way she was treated by the medical profession after years of feeling unwell and being told she should lose weight. She said her dying wish was that “women of size” should advocate for their health and not simply accept “that fat is the only relevant health issue.” “Over the past few years of feeling unwell, she sought out medical intervention and no one offered any support or suggestions beyond weight loss”, her obituary read.

Though the consequences of weight bias, in general, will be discussed in details in the subsequent sections, however, consequences specific to weight bias in a healthcare setting will be discussed here.

a. Delayed/missed diagnosis

As highlighted above, patients with obesity often suffer dangerous delays in getting a proper diagnosis because doctors tend to over-attribute symptoms to the patient’s overweight. In addition, certain diseases that create obesity as a symptom are often misdiagnosed as a weight problem. These diseases include polycystic ovary syndrome (PCOS), lipedema, hypothyroidism, Cushing’s syndrome and depression. Most of these conditions, except for lipedema, have been discussed in my post ‘Complications of obesity: the mother of all diseases’, referred to above.

Lipedema is a common condition, occurring almost exclusively in women, affecting up to 11% of women. Signs and symptoms of lipedema typically appear during puberty, pregnancy, or menopause. Symptoms vary from person to person, but usually include abnormal deposits of body fat in both legs, extending from the buttocks to the ankles. As the condition progresses, fat continues to build up and your lower body grows heavier. In the early stages of lipedema, most individuals have a normal appearance above their waist. As a result, while the bottom half of the body may be size 16, the top half of the body may be only size 8. While in some minor cases of lipedema, it stabilizes, in others, the disorder may progress and the chest, torso, abdomen and upper extremities may also become enlarged. Although it begins as a cosmetic concern, it can eventually cause pain and other problems. The skin overlying the affected areas usually appears normal, although it may lose elasticity. People with lipedema tend to bruise easily, possibly due to the increased fragility of small blood vessels within the fat tissue. Lipedema can often be mistaken for regular obesity or lymphedema.

b. Avoidance of preventive healthcare

When an individual living with obesity visits healthcare professional and experiences a judgemental response of disgust, anger or blame because of their size, this jeopardises their healthcare. These everyday attitudes have an impact beyond discomfort and embarrassment – patients report negative judgment from doctors because of their weight; they are upset about the kinds of comments made by the doctors about their weight; they perceive a lack of empathy from doctors because of their weight; they perceive that they won’t be taken seriously because of their weight; and they feel that their weight is unfairly blamed for all of their presenting problems. As a result, these patients have lower trust in their healthcare providers and patients with higher BMI may avoid seeking healthcare because of anxiety over being shamed for their weight, which could mean potentially missing out on a life-saving diagnosis. Thus, weight stigma is one of the potential pathways that contribute to higher rates of poor health.

In a study involving about 500 women with obesity who were delaying preventive healthcare services despite having high access to healthcare, they attributed their decisions to being disrespected by the healthcare providers for their weight; feeling embarrassed to be weighed; negative healthcare provider attitudes in the past; and the medical equipment being too small to be functional for their body size. These weight stigma-related barriers increased with women’s BMI; as a result, women with the highest body weight reported most of these barriers. The long-term result of avoidance and postponement of care is that people with obesity may present with more advanced, and thus more difficult to treat conditions. As terrible as it is to be denied a promotion or not being hired for a job because of your size, being diagnosed through the lens of a doctor’s weight bias could be lethal.

c. Switching physician

Some recent studies have also found that some patients with obesity switch doctors because of their perceived unfair treatment due to their body weight. In a study titled ‘Parental Perception of Weight Terminology That Providers Use With Youth’ published in the journal ‘Pediatrics’ in Oct 2011, researchers found that when parents were asked how they would react if a doctor referred to their children’s weight in a stigmatizing way, 34% responded that they would switch doctors, and 24% stated that they would avoid future medical appointments for their children. Parents rated the terms ‘fat’, ‘obese’, and ‘extremely obese’ as the most undesirable, stigmatizing, blaming, and least motivating. In contrast, more neutral words like ‘weight’ or ‘unhealthy weight’ were rated as the most desirable and motivating for weight loss.

d. Failure to lose weight

When patients feel judged by their healthcare providers on the basis of their weight, they feel reluctant to discuss their weight. Even when they do seek medical care, weight loss attempts are less successful.

Though reasons for weight bias, in general, would be discussed in the next section, in the context of healthcare professionals, the weight bias seems to stem from two reasons. Firstly, healthcare professionals are also exposed to the same social messages about obese persons as is the general population and are even more aware of the negative health consequences of obesity. Secondly, and something of greater concern, healthcare providers often view obesity as an avoidable risk factor that impedes their ability to treat and prevent disease. Therefore, the resultant frustration that physicians may feel towards ‘difficult’ or ‘complex’ patients may further complicate the negative emotions associated with the implicit and explicit bias they may hold. The perspective that obesity is an avoidable risk, for which patient himself is to be blamed, remains largely unchallenged. As a result, healthcare providers may be less self-aware of their propensity to and feel less pressure (internally or from external sources) to behave in a non-prejudicial way towards people with obesity.

4. Weight bias in a workplace setting

Unemployment is a longstanding topic of concern across the world; unemployment affects the unemployed individual and his family, not only with respect to income but also with respect to health and mortality. Unfortunately, weight bias is also very prevalent in the employment setting, including hiring inequities because of weight, and also one where gender differences may emerge. Studies have shown that people with obesity are associated with low competence, receive lower starting salaries, are ranked as less qualified, work longer hours than normal weight employees, are more likely to be terminated from job and experience weight stigma from co-workers because of their weight. Studies have also suggested that obesity and BMI are associated with employment in jobs associated with lower socioeconomic status.

As highlighted above, there are also reports of discrimination at the hiring stage, where obese candidates are assessed having less leadership potential, are less likely to be employed, and are expected to be less successful compared to normal weight peers. A research study titled – ‘Obesity Discrimination in the Recruitment Process: “You’re Not Hired!”’ was published in the journal ‘Frontiers in Psychology’ in May 2016. The study sample included employees employed in jobs varying in levels of physical demand (sedentary, standing, manual work and heavy manual work) from three European countries (Czech Republic, Slovenia and the UK). The major findings of the study are summarised below:

• First, the findings demonstrated that obese candidates were discriminated against when applying for work compared to normal weight candidates and when the weight status of the candidate was not revealed.
• Second, the findings demonstrated that obese candidates were evaluated as less suitable across all four workplaces of different physical demand, in particular by participants from heavy manual workforces. It is likely that stereotypes of obese people as less physically capable and slothfulness have contributed to this finding.
• Third, the study findings demonstrated that female candidates were perceived as less suitable across all photo conditions compared to male candidates.

Other studies too have reported gender differences in obesity discrimination and findings suggest that obese women are more likely to be discriminated against than obese men when applying for a job, especially if the job requires high visibility and physical demands. Various studies have reported the extent of the discrimination from 3 times to as high as 16 times. While there is certainly evidence of weight discrimination toward men in employment settings, it appears to be less severe and occurs at higher body weights compared to women. This could be because, as suggested by ‘sexual objectification theory’, women are subjected to sexual objectification and assessment against beauty standards. This discrimination in the hiring process holds serious implications for the employment of obese females.

5. Weight bias in Mass Media

Media, such as television or written press is a major contributor to the development and maintenance of anti-fat attitudes. The media often not only perpetuates stereotypical portrayal of people with obesity but also reinforces the social acceptability of weight bias. For instance, the media portrayal of people with obesity as a source of derogatory humour – lazy, gluttonous and undisciplined, is socially accepted in most cultures. This stigmatizing portrayal of characters with obesity is also prevalent in popular children’s television shows and movies, where characters with larger body sizes are depicted as aggressive, unpopular, evil, unhealthy, gluttonous, and target of humour or ridicule. In contrast, visually slim characters are portrayed as being kind, popular and attractive. A study titled ‘Pass the Popcorn: Obesogenic Behaviours and Stigma in Children’s Movies’ published in the journal ‘Obesity’ in Jul 2014, concluded that obesogenic content was present in the majority of popular children’s movies and commonly recurred throughout the movies.

Although practices such as bullying are often discouraged by schools and parents, movies often contain messages tacitly encouraging these behaviours towards overweight and obese people. Studies have shown that greater media exposure among children is associated with greater obesity-related stigmatizing attitudes toward peers with overweight and obesity. What is perhaps of greater concern is that media framing of obesity places great emphasis on individual responsibility; the discourse used in the media when reporting on obesity represents an attempt to create concern and a ‘moral panic’. This leads to an emotional response in the recipient and reinforces and adds to the weight stigma. 

What Causes weight bias and discrimination?

1.Although more research is needed on the root causes of weight bias, a fundamental driver of weight bias is a lack of understanding of obesity. People often think that individuals living with obesity are personally responsible for their weight because they just eat too much or do not exercise enough. A popular narrative on obesity being

“Look what he’s done to himself; if only he had some self-control, or wasn’t so lazy.”

            However, as explained in details in my post ‘Is obesity a disease or a risk factor for other conditions?’ obesity is far more complex than simply eating too much or exercising too little.

2. A weight-centric approach in which weight is viewed as a proxy for health and beauty has played an important role in propagating weight bias. Our society not only derogates obese individuals but also glorifies thinness. As discussed in the preceding sections, popular media portrays thin people as beautiful and in control while depicting overweight people as lazy, gluttonous and lacking willpower. As discussed, because of the sexual objectification, women particularly seem to experience higher levels of weight stigmatization than men, even at lower levels of excess weight.

3. Another important factor which often propagates and tends to give social ‘acceptability’ to weight-based stigmatization is the general belief that stigma and shame will motivate people to lose weight. Way back in 2010, a news report involving an interview with the British Public Health Minister emerged out of the UK and received international media attention. In her interview, the minister urged doctors to call their overweight patients “fat” rather than “obese”. She said “doctors and healthcare workers are too worried about using the term ‘fat’ – but doing so will motivate people to take personal responsibility for their lifestyles. Calling them ‘obese’ does not provide sufficient motivation. Just call them ‘fat’: plain-speaking doctors will jolt people into losing weight.” Research shows that a very large percentage of discussion about obesity on social media, especially Twitter and Facebook, are of fat-shaming nature. However, as will be discussed in the subsequent sections, research shows that fat-shaming has the opposite effect.

4. Weight bias among parents may in part stem from the stigma that parents themselves perceive because their child is overweight or obese. In a study titled ‘Cause and Effect Beliefs and Self-esteem of Overweight Children’ published in the journal of ‘Child Psychology and Psychiatry’ in Sep 1997, parents reported getting negative feedback and criticism because of their child’s obesity. They were often accused of having it in their power to control their child’s obesity. These comments aroused feelings of guilt and self-doubt in some parents, who felt unable to respond to these remarks. Though parents tried to act as buffers to protect their child from the teasing and humiliation in school, neighbourhood, and in their own families, however, some of them reported that they are often frustrated and angry over their child’s failure to lose weight because they believe that weight reduction is the only way of decreasing negative feedback.

In another study titled ‘Parent’s perceptions of health professional’s responses when seeking help for their overweight children’ published in the journal of ‘Family Practice’ in Mar 2005, some mothers reported that healthcare providers left them feeling blamed and responsible for their child’s weight status.

In brief, parents of obese children may feel pressure and negative evaluation by others if their child is overweight or obese. This perceived parental responsibility combined with the general belief among the parents that they were unable to resolve the problems associated with their child’s obesity, may create an atmosphere of helplessness, frustration and anger in the household. It is likely that at times even the best-intending parents can end up taking out their frustration, anger and guilt on their overweight child by adopting stigmatising attitudes and behaviour, such as making critical and negative comments toward their child.

5. Public health-promotion campaigns if not carefully thought-out, despite being well-intended, may contain stigmatising messages/terms. For example, the Children’s Healthcare of Atlanta, USA launched a campaign ‘Strong4Life’, which was described as “a wellness movement designed to ignite societal change and reverse the epidemic of childhood obesity and its associated diseases in Georgia”. On the billboards and websites, the campaign used images of children with obesity, with captions such as “Warning: Big bones didn’t make me this way, big meals did.” As highlighted above, simplifying obesity and blaming it on the individual child, is stigmatising. Research has shown that such obesity-related public health media campaigns do not evoke a favourable response from participants, with very few intending to comply with the message content. Efforts that promote weight loss to ‘improve’ one’s appearance can also propagate weight bias if their messages equate thinness with health and/or beauty and could promote disordered eating patterns.

What are the consequences of weight bias?

As highlighted in the preceding sections, people with overweight/obesity face weight bias from multiple sources – from peers, educators, healthcare providers, co-workers, media and even parents. The impact of weight bias on people with overweight/obesity is significant and has negative consequences for their psychological, social, physical and physiological health, over and above the health risks associated with obesity.

1. Emotional and psychological effects

As highlighted in the preceding sections, weight bias can take the form of teasing and bullying. In fact, in comparison with sexual orientation, race or ethnicity, religion, academic ability, family income and physical disability, body weight is the most common reason for bullying in youth. Of added concern, as highlighted before, many of them face teasing and bullying from trusted adults; studies reveal, over a third report experiencing teasing and bullying about their weight from parents.

Experiencing weight-based teasing and bullying increases the risk for a range of emotional and psychological consequences for the affected person. Studies have shown that when people experience weight bias, they have increased vulnerability to:

• Feelings of shame, leading to depression, anxiety and other psychological disorders.
• Poor body image and body dissatisfaction.
• Low self-esteem and self-confidence
• Feelings of worthlessness and loneliness.
• Substance abuse
• Self-harm behaviours and suicidality. Research has found that obese youth who are victimized by their peers are two to three times more likely to engage in suicidal thoughts and acts compared with same-weight peers who have not been teased.

2. Social isolation

Weight-based teasing and bullying also contribute to social isolation and adverse academic outcomes. In the preceding sections weight bias in different life domains has been discussed. Weight bias also has consequences for the social relationships of people with overweight/obesity. Studies have revealed that children and adolescents with overweight/obesity are more likely to be socially isolated and are less likely to be befriended by their peers compared to non-overweight peers. Studies have revealed that youth are keenly aware at an early age about the impact of their weight on social relationships. In a study of 9 to 11 years old children, more than two-thirds children who perceived themselves as being overweight, believed they would have more friends if they could lose weight. Research has also shown that people with overweight and obesity may struggle more to attract romantic partners, and therefore have lower rates of marriage.

3. Poor academic performance

This social isolation may negatively impact academic performance. This is further compounded by children with overweight/obesity missing more number of days of school to escape weight-based teasing and bullying and weight-based attitudes on part of teachers, which can lead them to form lower expectations of students with overweight/obesity.  All these factors put together can lead to lower educational outcomes for children and young people with obesity. This, in turn, can affect children’s life chances and opportunities, and ultimately lead to social and health inequities.

4. Physical health effects

Various research studies have shown that weight bias triggers physical health behaviours or lifestyle behaviours with a potential to worsen obesity.

a. Unhealthy eating behaviours

Weight bias and associated stigma is a form of stress – both acute and chronic. Vast literature in psychology substantiates that eating and turning to food is a common coping strategy to deal with psychological distress. Controlling food and body is their way of relieving distress and achieving some degree of control over their life. For a person experiencing psychological distress, their world feels like an unsafe place, and for many complex reasons, an eating disorder provides them with a sense of safety; food can be soothing, it alters mood and distracts the person with the disorders from their trauma.

Therefore it is not surprising to find that people experiencing weight stigma engage in unhealthy eating behaviours and binge eating compared to peers who were not teased. In a study involving over 2400 women in a self-help weight loss organisation, 79% reported turning to food as a coping mechanism to the trauma associated with weight bias. The internalisation of weight bias tends to increase the risk of eating disorders. These coping strategies are not unique to adults; research has found that these patterns may start quite early. Both boys and girls, who reported emotional distress in response to weight-based teasing and bullying from peers and parents, were more likely to engage in emotional eating and binge eating. Emotional eating means you eat for reasons other than hunger. You may eat because you are sad, depressed, stressed or lonely. Or you may use food as a reward. Binge eating disorder (BED), on the other hand, is defined by regular episodes of binge eating accompanied by feelings of loss of control and in many cases, guilt, embarrassment and disgust.

Of added concern, disordered eating behaviours in response to early experiences of weight-based teasing may be long-lasting over many years and into adulthood. A research study titled ‘Fatty, Fatty, Two-by-Four: Weight-Teasing History and Disturbed Eating in Young Adult Women’ was published in the ‘American Journal of Public Health’ in Mar 2013. The study involving young adult women demonstrated that participants who experienced childhood weight-teasing were significantly more likely to have disturbed eating behaviours now than non-weight-teased peers. Also, as the variety of weight-based teasing insults increased in childhood, so did the disturbed eating patterns and the current body weight status in adulthood.

Another study examined a cohort (a group of people with shared characteristics) of 1800 people from the Project EAT study, which is a cohort-based study in the US, to examine eating and physical activity patterns in teens and young adults. The study found that both men and women who experienced weight-based teasing in adolescence had increased odds of obesity, disordered eating and poor body image 15 years later. These coping responses that worsen eating behaviours persist over time because once trapped within the eating disorder, people often feel they need to maintain it in order to survive. They don’t know who they are or how they could cope without it.

b. Reduced exercise and physical activity

Another lifestyle behaviour that is affected by weight bias is physical activity. Research studies have found that individuals who experience weight bias tend to have more negative feelings towards exercise and are more likely to avoid exercising in public for fear of being shamed for their weight. Similar behaviour towards physical activity has been found in youth. Students who experience weight-based teasing by peers tend to have less self-confidence in being physically active. This is particularly concerning in view of the high prevalence of weight bias in physical activity settings. Studies have reported that as many as 85% of adolescents reported witnessing their peers being teased about weight, specifically during gym class at school.

Various studies have found strong implicit anti-fat attitudes even among the physical education teachers. Students have reported feeling upset by such negative comments from teachers about their athletic abilities, resulting in their avoiding participation in physical activity classes. Given the importance of encouraging overweight and obese children to participate in physical education and activity, these findings raise serious concern.

c. Worsening obesity

Disordered eating and reduced physical activity increase the risk of developing and or worsening overweight/obesity over time. Additionally, the effects of weight-based teasing in adolescence on weight gain are seen even several years later.

5. Stress-induced pathophysiology

The term pathophysiology is a convergence of pathology with physiology. Pathology is the medical discipline that describes conditions typically observed during a disease state, whereas physiology is the biological discipline that describes processes or mechanisms operating within an organism. While pathology describes the abnormal or undesired condition, pathophysiology seeks to explain the functional changes that are occurring within an individual due to a disease or pathologic state.

 As highlighted above, weight bias and associated stigma is a form of stress – both acute and chronic. Though stress is a separate topic in itself, it will be discussed here briefly so as to enable a better understanding of the health consequences of the weight bias-related stress. For optimum functioning of the human body, it must maintain its internal environment viz. body temperature, fluid balance, blood pH (a measure of acidity or alkalinity), and oxygen tension within narrow limits. The ability of an organism to maintain the internal environment of the body within narrow limits, despite changes in the external environmental conditions, diet or level of activity, is known as homeostasis. The process that achieves or maintains homeostasis is known as allostasis. The term allostasis means ‘achieving stability through change.’ Essentially, while homeostasis describes a certain condition, allostasis is a process. Allostasis is mediated through both physiological as well as behavioural changes. The allostatic system enables an organism to respond to its changing physical state (e.g. lying, standing, exercising) and to cope with the various stressors in the environment such as extremes of temperature, physical danger, psychological stress, various infections, hunger, isolation, crowded and noisy neighbourhood, having to give a speech in public etc.

The physiological changes are primarily controlled by the hypothalamus, a small region of the brain located at the base of the brain. Two of its major functions are to regulate the endocrine system (a chemical messenger system consisting of hormones) through the pituitary gland (a pea-sized body attached to the base of the brain, often called the master gland because it controls several other hormonal glands in the body, including adrenal glands) and to regulate the autonomic nervous system (ANS). ANS is a part of the peripheral nervous system which controls the involuntary body functions such as breathing, blood pressure, heart rate and the dilation or constriction of key blood vessels and small airways in the lungs called bronchioles. The ANS has two components – the sympathetic nervous system and the parasympathetic nervous system.

The sympathetic division regulates the use of metabolic resources and coordinates the emergency response of the body to potentially life-threatening situations, a response which is commonly referred to as “fight-or-flight” response, which helps a person to either fight the threat off or flee to safety. The parasympathetic division usually presides over the restoration of metabolic reserves and the elimination of waste; it acts as a brake and promotes the “rest and digest” response that calms the body down after the danger has passed.

The term stress is a highly subjective phenomenon and defies definition. However, it may be understood as ‘a state of mental or emotional strain or tension resulting from adverse or demanding circumstances.’ Some stress can be beneficial at times, what is known as ‘eustress’ (the term was coined by endocrinologist Hans Selye, consisting of the Greek prefix eu- meaning “good” and stress, literally meaning “good stress” or positive stress), producing a boost that provides the drive and energy to help people get through situations like exams or work deadlines. However, an extreme amount of stress, what is called as distress (a state in which a person is unable to completely adapt to stressors and their resulting stress and shows maladaptive behaviours; also known as negative stress) can have health consequences and adversely affect the immune, cardiovascular, neuroendocrine and central nervous system.

Stress involves a stressor (an activity, event or other stimuli that causes stress) and a stress response. Stressors are broadly classified as physical or psychological. Physical stressors include trauma, injury, illness, heavy physical exertion, noise, overcrowding, excessive heat or cold etc. On the other hand, psychological stressors include interpersonal conflicts, isolation, traumatic life events, high job demand, and various biases in society, including weight bias and associated stigma.  However, what is important is that the response of the body to all stressors is similar.

In response to a stressor, the hypothalamus sets off an alarm system and the body responds to it by turning on an allostatic response. The two primary allostatic responses involve the activation of the sympathetic nervous system and the pituitary gland by the hypothalamus, which in turn stimulate the adrenal glands (located atop the kidneys) to release a surge of a mix of hormones, mainly including adrenaline (also known as epinephrine) and cortisol. These hormones are colloquially known as ‘stress hormones’. Adrenaline increases your heart rate, elevates your blood pressure, increases breathing rate, and widens the small airways in the lungs enabling increased uptake of oxygen, sharpens hearing and other senses and boosts energy supplies. Cortisol, the primary stress hormone, increases blood sugar levels, an important energy fuel, and also curbs body functions that would be nonessential or detrimental in a fight-or-flight situation. It alters immune system responses and suppresses the digestive system, the reproductive system and the growth processes. Thus, the net effect of these changes is that the body is prepared for the demands of a fight-or-flight situation.

There are two important features of the physiological stress response – the first involves turning it on in amounts commensurate to the degree of the stressor; the second, and the equally important, component is turning off the response when the challenge has passed, which allows the stress hormones to return to their baseline levels. Thus, in a normal allostatic response, an alarm is sounded in response to a stressor and an allostatic response, involving output of the stress hormones is initiated; it is sustained for the duration of the challenge and then turned off. However, there are times when an individual is confronted with many adverse life events or the stressor persists for a long time. At times the allostatic responses are dysregulated, i.e. either there is an inadequate response to a stressor or it is not turned off when the challenge is over. When there is a delayed shutdown, it results in a prolonged allostatic response.

When the alarm response is sustained over weeks, months or even years, it results in exposure to elevated levels of stress hormones over prolonged periods. This state of sustained activity levels of stress hormones is known as ‘allostatic state’. The cumulative effect of the allostatic state over time results in ‘allostatic load’  and ‘overload’ (a state of very high allostatic load), which is synonymous with the ‘wear and tear’ of the body and brain that results from being stressed out.

The most important aspect of the stress hormones is that they have both protective and damaging effects on the body, depending on the time course of their secretion. In the short run, as long as the allostatic response is limited to the period of challenge, allostatic response promotes adaptation to the stressor, and maintains homeostasis, thereby promoting survival of the organism. However, over longer time intervals, allostatic load (and overload), as a result of accumulated exposure to high levels of stress hormones can result in serious health conditions including anxiety, insomnia, muscle pain, high blood pressure, chronic fatigue, and a weakened immune system. The consistent and ongoing increase in heart rate, blood pressure and the stress hormones can contribute to the development of major illnesses such as heart disease (heart attack), stroke, diabetes, depression and obesity. Research also shows that both acute and chronic stress predispose individuals to abuse of addictive substances.

In males, chronic stress can affect testosterone production resulting in a decline in sex drive or libido, and can even cause erectile dysfunction or impotence. Chronic stress can also negatively impact sperm production and maturation causing difficulties in couples who are trying to conceive. In women, high levels of stress may lead to irregular menstrual cycles or cessation of cycles, more painful periods, and changes in the length of cycles. It may also reduce sexual desire. Excess stress during pregnancy increases the likelihood of developing depression and anxiety during this time. Maternal stress can negatively impact foetal and ongoing childhood development and disrupt bonding with the baby in the weeks and months following delivery.

Addressing weight bias and obesity stigma.

As discussed in the preceding sections, weight bias has a severe impact on personal relationships, educational attainment, professional achievement, healthcare delivery and psychological and physical health of people with overweight/obesity. Weight bias often happens in quiet and subtle ways, of which people doing the stigmatizing act may not be even aware of (implicit bias), even though it is hurtful and demoralizing to those on the receiving end.

The WHO Commission on Ending Childhood Obesity, which submitted its final report to the WHO Director General on 25^th Jan 2016, recognised that obesity among children is associated with stigmatisation and reduced educational attainment. The Commission also affirmed that governments and society have a moral responsibility to act on behalf of children to reduce the health and social consequences of obesity. In endorsing the Commission’s report and adopting its recommendations by means of a World Health Assembly resolution, Member States have acknowledged that discrimination against children with obesity by healthcare professionals and others is unacceptable and that stigmatization and bullying should be addressed.

As is evident from the above discussion on the effect of weight bias on worsening obesity, it is clear that to tackle the obesity ‘epidemic’, the parallel epidemic of obesity stigma also needs to be addressed.

Strategies to address weight bias

1. Education about the causes of obesity

As has been highlighted in the preceding section on causes of weight bias, there is a pervasive misconception that people with obesity are personally responsible for their weight because they just ‘eat more and move less’. Such beliefs lead to increased stereotyping and weight bias. There is a need to improve understanding of obesity so that people with obesity are not defined by their body size or shape. Instead, they need to be seen as ‘whole person’ with social, physical and emotional needs like anyone else.

As explained in my post ‘Is obesity a disease or a risk factor for other conditions?’, referred to above, obesity is a complex disease and in addition to the individual choices, a range of factors including genetic, biological, environmental and social factors contribute to obesity. These factors are beyond personal choice. People who understand this complex web of causality, have more positive attitudes about people with obesity and this helps reduce the weight stigma. This understanding is equally beneficial for patients too. Studies have found that when people with high body weight understand the complex causality of obesity, it can reduce self-blame and increases their belief in their innate ability for behavioural changes.

2. Delinking weight from health and beauty

As highlighted in the preceding sections, a weight-centric approach in which weight is viewed as a proxy for health and beauty has played an important role in promoting weight bias. Popular media has played an important role in such a portrayal – glamorising thinness while stigmatizing people with overweight/obesity. Body weight is not the sole factor which determines your health and well-being. As highlighted in my post ‘Is obesity a disease or a risk factor for other conditions?’, during the recent decades, many studies have provided evidence that obese subjects with an increased cardiorespiratory fitness have lower all-cause mortality and lower risk of cardiovascular and metabolic disorders and certain cancers, compared to people who are normal weight but physically unfit.

There is a need for advocating and maybe even legislating media and journalism guidelines for the portrayal of individuals with obesity in the media and stop the use of imagery and language that depict people with obesity in a negative light; instead there is a need to showcase positive stereotypes of people with overweight/obesity in the media.

3. Changing misconceptions about shaming

As discussed earlier, there is a mistaken belief in the society at large that shaming, harassing or criticizing people about their weight and/or eating patterns will motivate people to change their behaviour. However, treating people disrespectfully because of their weight is harmful to their physical and mental health and it does not result in positive behaviour change related to weight loss. Often, the higher weight individuals already engage in self-blame and feel ashamed of their weight. This is evident from a campaign launched in the UK to end the stigma of obesity – “I don’t need reminding I don’t like myself: Campaign to end the stigma of obesity”.

Rather than motivate positive change, fat-shaming causes stress and may lead to people overeating and avoiding physical activity, as discussed above. Therefore, weight-shaming as a tactic to address obesity is not justified. Instead, there is a need to sensitise health professionals, educators, policymakers and the public at large, to the adverse impact of weight bias and fat shaming on health and well-being. The public at large should be sensitized and educated about the acceptance of body diversity. Kaz Cooke, an Australian author, cartoonist and broadcaster, in her book “Real Gorgeous: The truth about Body & Beauty’ written in 1996, asks “What size should I be?” For her answer, she does not refer to the usual insurance company height-weight charts. Instead, she points out that people’s body shapes and sizes are the results of many factors. These factors include people’s genetics, the environments they grew up in, their stages in life, their nutritional intakes, their cultural norms and their lifestyles. Ultimately, Cooke’s answer is…Me-size. As silly as that may sound, it’s true. Believe it or not, body size diversity is normal.

4. Assess healthcare campaigns for any stigmatising messages

Public health-promotion campaigns address not only the people with overweight/obesity but also the society at large. As highlighted in the preceding sections, health-promotion campaigns if not well thought out, may have unintended consequences on the lives and experiences of people with obesity. Fat-shaming messages, explicit or implicit, encourage weight bias by condoning it. Therefore, it is necessary to ensure that such campaigns do not simplify obesity (i.e. project it as simply an outcome of individual choices such as eating more and moving less) and do not use stigmatising language.

Public health messages should encourage healthy behaviours by emphasising on modifying health-promoting behaviours, which would improve health for all, irrespective of body weight, rather than emphasising on body weight or size. Such campaigns while promoting healthier diets and physical activity, should try to promote mental health resilience and body positivity among people with overweight/obesity.

5. Address weight bias in schools

As has been highlighted in the preceding sections, school is a common setting where weight bias occurs and has a serious impact on the academic performance of the children. In view of the same, there is an urgent need for advocating and maybe even legislating, anti-bullying programmes in schools. Since educators are also a source of weight bias, it would be desirable to conduct training for education professionals on weight-related issues. In fact, educators should play a pivotal role in implementing anti-bullying programmes in schools. Modify the built environment to accommodate children of all sizes. For e.g. chairs in classrooms, library etc. should be sturdy and armless.

It is also important to empower families and children with overweight/obesity to cope with stigmatising situations and address weight stigma not only in schools but also in their communities, and most importantly within their homes. Parents of children with overweight/obesity should actively interact with their children’s teachers and school administrative staff to promote awareness of weight bias in schools as well as to ensure that programmes/policies to address weight-based victimization are being implemented in their schools. Equally important, parents should also be sensitized to the potential stigma at home from family members and friends. Promote mental health resilience and body positivity among children with overweight/obesity.

6. Addressing weight bias in workplace settings

There is a need for advocating and maybe even legislating laws against weight-related discrimination in the workplace.

7. Addressing weight bias in healthcare settings

There is a need to help people experiencing weight stigma to overcome the barriers that arise as a result of weight stigma, which can prevent people from getting access to healthcare. Various strategies recommended to be practised to address weight stigma in healthcare settings are as under:

a. Increase awareness about personal attitudes and assumptions about bodyweight                 

As highlighted in the preceding text, often the healthcare providers harbour both implicit and explicit weight bias. Implicit attitudes lie outside conscious awareness and occur automatically. Implicit weight biases can affect our body language, our tone of voice, our facial expressions and gestures, our eye contact and even the spatial distance that we maintain with our patient. For example, a thinner patient may receive eye contact and smile from a physician who walks into the room, whereas the same physician might avoid eye contact with a heavier patient. In view of the above, it is important for healthcare professionals to be sensitized about their implicit weight biases and the resultant non-verbal behaviours and their impact on the patient. Practising emotion regulation techniques can help us take charge of our negative emotions.

b. Training for healthcare professionals and students about weight-related issues

As highlighted in the preceding sections, weight bias is often present long before healthcare professionals enter clinical practice. As knowledge about the complex causes of obesity leads to reduced weight stigma, healthcare professionals and medical students need to be educated about weight-related issues. As, traditionally medical colleges/schools, provide limited training on obesity, more so on aspects like weight bias, there is a need to advocate for inclusion of training to address obesity and weight stigma, in the curriculum of medical colleges/schools. For practising physicians, Continuing Medical Education (CME) programs could be conducted.

The training must address obesity, including its complex causes (e.g. biological, genetic and environmental contributors beyond personal control); weight bias, including how it is perpetuated and it’s potentially harmful effects on their patients; approaches to empower people to make healthy behavioural (lifestyle) changes; and communication skills training. Healthcare providers hold the power to profoundly affect patient’s thoughts, feelings and behaviours. To advance as an equal society, healthcare providers should lead the way for weight stigma eradication.

c. Promote the use of respectful and sensitive communication

Use of respectful and sensitive communication is one of the most important strategies to reduce weight bias in the healthcare setting. While it is important for people with overweight/obesity to understand the current and future health risks associated with the degree to which a person weighs more than what is healthy, the information should be communicated in a sensitive and supportive manner. Avoid language that contributes to or reinforces weight bias, even indirectly. Words can heal or harm, intentionally and unintentionally. In the preceding section on weight bias in a healthcare setting, it had been discussed how patients, as well as parents of children with obesity, find words such as “fat”, “obese”, “extremely obese”, and “morbidly obese”, stigmatizing, blaming and least motivating. In contrast more neutral words like “weight”, “unhealthy weight”, or “very unhealthy weight” were rated as most desirable and motivating for weight loss.

Another consideration in improving communication to reduce weight stigma is the use of “People-first language”. People-first language involves placing the individual first, before the medical condition or the disability, rather than labelling them by their disease or disability. It has become an established standard for respectfully addressing people with mental and physical disease or disability and plays an important role in reducing the stigma associated with these illnesses. ‘The American Medical Association (AMA) Manual of Style’, a guide for authors and editors, requires authors to:

“Avoid labelling (and thus equating) people with their disabilities or diseases (e.g. blind, schizophrenics, and epileptics). Instead, put the person first. Avoid describing persons as victims or with other emotional terms that suggest helplessness (afflicted with, suffering from, stricken with, maimed). Avoid euphemistic descriptions such as physically challenged or special.”

As an example, they advise authors to refer to ‘persons with diabetes’, rather than ‘diabetics’.

In the context of obesity, this involves phrases such as ‘person with obesity’ rather than ‘obese person’. Unfortunately, although the people-first language has been widely adopted for most chronic diseases and disabilities, it has not been adopted for obesity. As highlighted in the preceding text, referring to individuals with excess weight as ‘obese’ creates negative feelings towards individuals with obesity and perpetuates weight bias; it also gives rise to negative emotions in the targeted person. It needs to be understood that while ‘obesity’ is a disease, ‘obese’ is an identity. There is growing evidence to suggest that people-first language affects attitudes and behavioural intentions towards persons with disabilities. By separating the disease from the person we can pursue the disease while fully respecting the person affected. Patients with obesity should be treated with the same level of respect and empathy as their slimmer counterparts.

We can go a step further, beyond specific word choice and adopt strategies which support patients and families in making sustainable, healthy behavioural changes. Motivational interviewing is one such patient-centred approach which can be adopted by healthcare professionals. The American Academy of Pediatrics Institute for Healthy Childhood Weight has developed a free “Change Talk: Childhood obesity” online resource for providers to learn and practice motivational interviewing skills.

d. Create a welcoming clinical environment

Creating a supportive clinical environment to accommodate the needs of patients with diverse body sizes can help reduce stigma. Following aspects of the clinical office environment need attention to address weight stigma.

• Appropriate seating arrangements – Waiting room should have a variety of sturdy, armless seating options, which can support the weight of a patient of high body weight and which allows a larger size patient to comfortably sit down.
• Weighing scale in the clinic room should be placed in a private area and should have proper stability and weight capacity for individuals of higher body weight.
• Medical equipment such as blood pressure cuffs should accommodate and provide an accurate reading on a large arm.
• Gowns should be of an appropriate size that allows larger patients to feel comfortable and not overly exposed when they change.
• Patient examination couch should be sturdy and be big enough to comfortably accommodate larger size patients.
• Hallways and doorways should be well-configured for patients of larger body size.

e. Reduce focus on body weight

Focussing solely on body weight runs the risk of missing other diagnoses, as illustrated by the example of Rebecca Hiles, in the preceding section. As highlighted above, DO NOT over-attribute symptoms and problems to obesity. Instead, explore all possible causes of a presenting problem and avoid assuming it as a result of an individual’s weight status. Also, screen for diseases that create obesity as a symptom (e.g. polycystic ovary syndrome, lipedema, or hypothyroidism).

 Under the series “What Your Patient is Thinking” articles, of ‘The BMJ’ (Originally called the British Medical Journal), one of the oldest medical journals, an article titled ‘Why there’s no point in telling me to lose weight’ was published on 21 Jan 2015. In the article, the patient Emma Lewis writes:

“When I worry that I might be unwell, I often try to avoid visiting a general practitioner. Almost every consultation I’ve ever had – about glandular fever, contraception, a sprained ankle – has included a conversation about my weight; and that’s inevitably the conversation that destroys any rapport or trust that might have existed between me and my doctor.”

 She goes on to add – “It’s just like a little reminder that my GP – like many other people in the world – sees me as a fat person first, and individual second. It makes me feel like a problem to be solved – something unpleasant that needs to be eliminated.” She further adds – “They give me the impression that my weight is the most important thing about me…They put me right back to where I was when I was a binging – fasting teenager: full of shame.” Finally, she concludes – “I’ve opted out of the weight loss game. If that makes me a non-compliant patient, then so be it. I am healthier and happier than I was when I hated myself. I just wish that my healthcare providers would work with me on that.”

‘Weight-normative’ approach (emphasises on weight and weight loss when defining health and well-being) is not an effective strategy for most people, because of difficulties encountered in losing weight and high rates of weight regain and weight-cycling, which will be discussed in subsequent posts. It also contributes to and reinforces weight-stigma. On the other hand, ‘weight-inclusive’ approach (emphasises and views health and well-being as multifaceted while directing efforts towards encouraging healthy behaviours, improving health access, and reducing weight stigma) has been shown to improve multiple health outcomes, including physical (e.g. blood pressure), metabolic (e.g. blood cholesterol levels), behavioural (e.g. binge eating disorder), and psychological (e.g. depression and anxiety). These improved indices add to the health and well-being of the patient.

To reduce the focus on weight, weigh the patient less frequently – for example, restrict weigh-ins to the well-being checkups and avoid weigh-ins when visits are not associated with weight-related reason. However, it is important to understand that reducing the focus on weight does not imply ignoring health risks and medical problems associated with obesity. In fact screening for the diseases and medical conditions for which obesity is a risk factor, and appropriately managing these conditions is an important aspect of improving health and well-being in all patients.  Rather, what approaches like ‘Health At Every Size’ (HAES) suggest is that health professionals offer the same treatment approaches for persons with overweight/obesity as for a person with normal weight, presenting with a similar problem. For example, in the case of a normal weight person presenting with high blood pressure, conventional wisdom suggests dietary changes, increasing aerobic physical activity, stress management, followed by medication, if necessary. However, when a person with overweight/obesity presents with the same condition, the patient is told to lose weight, regardless of the difficulties associated with weight loss and weight-loss maintenance.

In brief, the weight-inclusive strategy emphasises the importance of prioritizing health behaviours and health outcomes and quality of life, rather than just body weight or the number on the scale. You can refer to my post ‘Holistic Health Approaches: the Way to Wellness’ for a detailed description of holistic health.

f. Talk about weight stigma

People experiencing weight stigma look for help to cope with it, and one person they look up to is their healthcare provider. Unfortunately, very few healthcare providers talk to patients about weight stigma. Still worse, very few acknowledge it or express support or empathy to patients who experience it. Healthcare providers are conferred higher social status due to their profession and are thus ideal candidates to serve as valuable allies for heavier individuals facing fat shaming.

Keeping in view the health consequences of weight bias, healthcare providers must assess patients with overweight/obesity for the negative experiences associated with weight bias, including bullying, low self-esteem, poor school performance, depression and anxiety. By talking to your patients about weight stigma and disapproving it, you legitimise the patient’s experiences on one hand, while on the other hand, it offers healthcare providers an opportunity to implement helpful strategies to cope with weight stigma.

Conclusion

As discussed in this article, weight stigma poses a serious threat to the health of the individuals, probably as much as obesity itself. Therefore, there is an urgent need to combat weight stigma, which is widespread, including in unexpected areas such as family and healthcare settings. Doing so will help to improve the health and the quality of life of millions of people. Fat-shaming from influential people, such as politicians, healthcare providers, and people you trust, such as your parents and family members, is the most damaging.

We can address weight stigma by increasing awareness about this issue and its consequences; by being aware of our own weight-based attitudes and using respectful and sensitive language; by being conscious of our non-verbal behaviours that convey stigmatizing messages; healthcare providers creating a weight-inclusive, welcoming atmosphere which focusses on well-being and healthy behaviours rather than weight loss; and by healthcare providers talking to their patients about weight stigma and its impact on their lives.

It needs to be understood that a person’s weight is not indicative of his intelligence, character, work ethics, or any other skills, abilities and personal characteristics. Therefore, all people, regardless of their body size, deserve respect, equity, and dignity and to be able to live without stigma and discrimination. It is the responsibility of each and every one of us to respect everyone as human beings first and foremost. Healthcare providers need to shift the healthcare focus from weight to health and well-being.

We need to fight obesity, not obese people.