This blog was originally written for Dietetically Speaking in May 2020.
A personal note regarding this article. I am an able-bodied, straight-size* female with thin privilege**. I will not profess to fully understand what it means to be a person in a larger body because I have never experienced it. This article is written for those who (like me, until recently) are not aware of our own weight stigma and the damage it is doing. Whilst those in larger bodies are not immune to demonstrating weight stigma, much of the damage is done by those in bodies such as mine.
*Straight-size = an alternative to ‘normal’ ‘average’ or ‘healthy’, because these suggest that being plus size is the abnormal or unhealthy
**Thin privilege = I am viewed as thin and, therefore, my size does not dictate my day-to-day experiences. For example, I seek medical advice and my weight isn’t discussed irrelevant of why I booked the appointment, my size is not the first characteristic used when someone describes me and I can quite easily find clothes my size.
Let’s start as we mean to go on. The terms ‘overweight’ and ‘obese’ can be stigmatising in themselves so these have been used here only to accurately reflect research. Owing to debate on the most appropriate language when it comes to weight (I recommend this article for those interested), neutral terms such as ‘weight’ and ‘BMI’ have predominantly been used elsewhere. However, it is acknowledged that fat activists are reclaiming ‘fat’ and promoting its use as a neutral descriptor. It is used in this vein towards the end of this article.
What is Weight Stigma?
Weight stigma is defined as the social rejection and devaluation that accrues to those who do not comply with prevailing social norms of adequate body weight and shape’(1).
In short, it is negative attitudes towards those of a higher weight.
As with any stigma, it can lead to prejudice and, in turn, discrimination (2). Not only are the numbers experiencing weight discrimination increasing but it is the third most common form of discrimination in the UK, behind age and sex but ahead of race (3 – 4). This is particularly pertinent when we recognise that, of these, only age, sex and racial discrimination are legislated against in the UK (5).
Experiences of weight discrimination increase with weight and if female, but decrease with age (4).
However, although studies have predominantly focused on women, there is no doubt males are also subject to stigma (6). Additionally, it has been shown that males express more stigmatising attitudes, as do those who exercise more frequently and have a lower Body Mass Index (BMI) (7).
N.B. Within research, weight and its relation to health is often measured using the World Health Organisation’s (WHO) Body Mass Index (BMI). This uses weight and height to categorise the population as:
- Underweight (<18.5kg/m2)
- Healthy (18.5-24.9kg/m2)
- Overweight (25-29.9kg/m2)
- Obese (>30kg/m2)
This measure is criticised for being a crude means to assess health (8). However, it is used here to accurately report research.
The effects of weight stigma have been evidenced across education, employment and healthcare settings, with this latter piece perhaps the most concerning (9).
Despite being responsible for our health, evidence of stigmatising attitudes in healthcare practitioners is vast.
This has even been shown to be at similar levels to that of the general population, as well as amongst those specialising in obesity care (10 – 13).
What’s the Problem with Weight Stigma?
Some might argue that weight stigma is beneficial, on the basis that it ensures being of a higher weight isn’t the social norm and therefore motivates those of a higher weight to address their health (14). But this argument is flawed on a number of levels.
1. Don’t Assume Being of a Higher Weight is Always Unhealthy
It is largely believed that weight is directly related to our health, but research on this topic suggests it is not so simple.
Where research does suggest a relationship between BMI and mortality, it is typically seen that decreased life expectancy occurs at the extreme ends of the BMI spectrum (ie. being underweight or a very high weight).
The strength of the relationship in those classes as ‘overweight’ and moderately ‘obese’ (30-35kg/m2) is weak (15). Additionally, these epidemiological studies rarely account for factors such as fitness, diet quality, weight cycling, drug use and socioeconomic status, which all have a significant effect on our health. Where they are controlled for, the relationship between BMI and mortality lessens or disappears completely (16). Furthermore, it has been argued that being overweight may in fact be beneficial in some instances (17).
The ‘obesity paradox’ describes the protective effect of higher BMI that has been documented amongst older adults as well as those with established diseases, such as cardiovascular disease and type 2 diabetes (18 – 20).
Furthermore, there are a proportion of people with obesity who are metabolically healthy, for whom weight loss advice may both be misguided and detrimental (21 – 22).
This has led to the debate that metabolic factors (such as blood pressure) are more important than weight when it comes to disease risk and that the location of fat, rather than the amount of it, may be more important when it comes to determining health (23 – 24).
Supporting this, cardiorespiratory fitness has been shown to affect mortality independently of weight, meaning that overweight or obese individuals who are fit would not necessarily benefit from weight loss (25 – 26).
For those with metabolic risk markers (eg. raised LDL, ‘bad’ cholesterol) it may be beneficial to lose 5-10% of body weight, which is deemed clinically significant in medical guidelines (27).
However, approximately 37-57% who take up commercial weight loss programmes,, achieve less than 5% weight loss (28).
The guidelines themselves acknowledge that 3% is more realistic and that this needs to be maintained long-term, with little evidence to support that this can be done (29). Furthermore, the method by which this is done is important and it is not guaranteed to be beneficial for everyone (30 – 31).
Even on the rare occasion weight loss is achieved and successful in improving metabolic risk markers, this weight loss won’t necessarily mean a reduction from the ‘obese’ BMI category to the ‘normal’ weight category (32). In the context of weight stigma, this means individuals may have successfully improved health outcomes but still be subject to anti-fat attitudes that assume ill-health.
Additionally, given weight cycling and drastic weight loss can actually be detrimental to health, and health improvements have been made without the need for weight loss at all perhaps a new approach is needed (33 – 34).
The weight-inclusive approach to health recognises that a focus on weight is rarely effective and instead focuses on health behaviours in the pursuit of well-being (35).
Non-diet approaches to health, such as Health at Every size (HAES) and Intuitive eating, promote self-acceptance and challenge the societal norm of targeting weight loss as the first port of call in the pursuit of wellbeing.
Studies have shown that diet can successfully reduce hypertension independent of weight loss and that exercise can positively affect lipoproteins, a marker for cardiovascular health, without weight loss (36 – 37). Weight loss is not the only route to well-being, and the current tendency to veer towards this weight-normative approach is rarely successful, not always appropriate and sometimes damaging.
2. Weight Stigma is Bad for Our Health
The negative health effects of stigma have been shown to be more damaging than overweight or obesity itself (38).
Given weight stigma is so pervasive, it has been speculated to be a mechanism by which overweight and obesity is linked to poor health (39).
Exposure to weight stigma has been linked to depression and anxiety, as well as physiological effects such as weight gain and increased likelihood of obesity (40 – 42). Alongside this, greater levels of HbA1c, a marker for blood sugar levels, have been observed in those experiencing frequent stigma as well as the stress hormone, cortisol (43 – 44).
In terms of behaviours, those who experience stigma have been shown to avoid healthcare, have less motivation to engage in health-promoting behaviours and increased incidence of disordered eating behaviours (45 – 47). Ultimately highlighting that weight stigma exacerbates obesity and is not an effective means to promote behaviour change. What’s more, these negative health effects exist even after weight loss (48 – 49).
Finally, weight stigma doesn’t only affect those of a higher weight. Weight bias internalisation (WBI) describes the internalisation of experienced stigma, and is characterised by acceptance and self-projection of societal attitudes towards being fat (50). WBI has been shown to be at similar levels in those who are overweight and non-overweight (<25kg/m2), and is shown to relate to disordered eating behaviours as well as poor physical and mental health (51 – 52).
Thus, the damaging effects of weight stigma can affect any of us as long as we are exposed to the stigmatising stereotypes and attitudes that pervade our society.
3. Weight is Not Simply a Result of Individual Behaviour
Weight stigma can be measured by the extent to which individuals agree with negative stereotypes associated with being fat (53).
Stereotypes that are commonly reported in the literature include laziness, lack of willpower and non-compliance (13, 54). These all denote personal responsibility as a cause for obesity, which is in line with attribution theory; that the extent to which obesity is perceived as controllable determines the extent to which stigma is expressed (55).
Ultimately, the more people blame an individual for their weight, the greater their stigma. However, more than one hundred factors are at play when it comes to weight (8).
Our weight is a result of genetics, physiology, environmental and social factors. These factors interplay without our control, with the ultimate result of regulating our body weight (56). Other considerations such as gut microbiota, medications, sleep and dieting history all influence our body weight, meaning the extent to which we are in control of our weight is far less than we like to think (16).
Where Do We Go From Here?
Weight stigma is prevalent, widespread and extremely detrimental to health. We need to challenge these norms as well as ourselves. The three key points highlighted above, and associated research, will hopefully help to do this.
Beginning by questioning our own conscious or unconscious biases when it comes to those of a higher weight.
In doing so, we can also start to recognise and challenge where these biases come into our day-to-day conversations, interactions and observations.
The way we behave and the opinions we hold affect others. Social consensus theory is one that prevails in the conversation regarding weight stigma, which is the idea that we are witness to the stereotypes held by those around us and accept them as our own (57).
This means both raising the topic with direct family and friends as well as looking at broader causes are beneficial.
Examples of raising the issue of weight stigma at a higher level include: lobbying the media to address their portrayals of fat people and supporting challenges to damaging public health campaigns, such as the recent Cancer Research UK campaign where the health impact of obesity was directly compared to smoking on billboards (58).
To start though, perhaps first look to the many amazing people working to change the conversation. Both for more lived experiences of being fat, as well as those working to change the norm and hold society accountable for the damage we are doing.
What is most important is that we are open to criticism and willing to recognise stigma and internalisation in ourselves. Only with this can we hope to address the extent to which stigma is rooted in our culture.
- Fat activists and body positive accounts on instagram (a select few!): @bodyposipanda @yrfatfriend @scarrednotscared
- Intuitive eating: @evelyntribole (Book: Intuitive Eating. A revolutionary programme that works) @laurathomasphd (Book: ‘Just Eat it’ and podcast: ‘Don’t Salt My Game) @kristamurias @themindfuldietitian @nudenutrition @isarobinson_nutrition @foodandfearless @antidietriotclub
- Other books: ‘Health at Every Size’ by Linda Bacon, ‘Eat Up’ by Ruby Tandoh, ‘Bad Science and the Truth about Healthy Eating’ by The Angry Chef.
- Tomiyama AJ, Carr D, Granberg EM, Major B, Robinson E, Sutin AR, et al. How and why weight stigma drives the obesity “epidemic” and harms health. BMC Med. 2018;16(1):1–6.
- Corrigan PW, Larson JE, Rüsch N. Self-stigma and the “why try” effect: Impact on life goals and evidence-based practices. World Psychiatry. 2009;8(2):75–81.
- Andreyeva T, Puhl RM, Brownell KD. Changes in perceived weight discrimination among Americans, 1995-1996 through 2004-2006. Obesity. 2008;16(5):1129–34.
- Jackson SE, Steptoe A, Beeken RJ, Croker H, Wardle J. Perceived weight discrimination in England: A population-based study of adults aged ≥50 years. Int J Obes [Internet]. 2015;39(5):858–64. Available from: http://dx.doi.org/10.1038/ijo.2014.186
- UK Government. Equality Act 2010. Explan Notes. 2010;2010(April):1–216.
- Himmelstein MS, Puhl RM, Quinn DM. Weight Stigma in Men: What, When, and by Whom? Obesity. 2018;26(6):968–76.
- Flint SW, Hudson J, Lavallee D. UK adults’ implicit and explicit attitudes towards obesity: A cross-sectional study. BMC Obes [Internet]. 2015;2(1):1–8. Available from: http://dx.doi.org/10.1186/s40608-015-0064-2
- Butland B, Jebb S, Kopelman P, McPherson K, Thomas S, Mardell J, et al. Tackling Obesities : Future Choices – Project report. Gov Off Sci. 2007;1–161.
- Puhl RM, Heuer CA. The stigma of obesity: A review and update. Obesity. 2009;17(5):941–64.
- Phelan SM, Burgess DJ, Yeazel MW, Hellerstedt WL, Griffin JM, van Ryn M. Impact of weight bias and stigma on quality of care and outcomes for patients with obesity. Obes Rev. 2015;16(4):319–26.
- Sabin JA, Marini M, Nosek BA. Implicit and Explicit Anti-Fat Bias among a Large Sample of Medical Doctors by BMI, Race/Ethnicity and Gender. PLoS One. 2012;7(11):1–7.
- Teachman BA, Brownell KD. Implicit anti-fat bias among health professionals: Is anyone immune? Int J Obes. 2001;25(10):1525–31.
- Schwartz MB, Chambliss HON, Brownell KD, Blair SN, Billington C. Weight Bias among Health Professionals Specializing in Obesity. Obes Res. 2003;11(9):1033–9.
- Callahan D. Obesity: Chasing an Elusive Epidemic. Hastings Cent Rep. 2013;43(1):34–40.
- Bacon L, Aphramor L. Weight science: Evaluating the evidence for a paradigm shift (Health at every size). Clin Nutr Interface Between Metab Diet, Dis. 2011;335–66.
- O’Hara L, Taylor J. What’s Wrong With the ‘War on Obesity?’ A Narrative Review of the Weight-Centered Health Paradigm and Development of the 3C Framework to Build Critical Competency for a Paradigm Shift. SAGE Open. 2018;8(2).
- Flegal et al. ASsociation of All-Cause Mortality with overweight and obesity using standard BMI categories. 2013;309(1):2010–2.
- Janssen I, Mark AE. Elevated body mass index and mortality risk in the elderly. Obes Rev. 2007;8(1):41–59.
- Winter JE, MacInnis RJ, Wattanapenpaiboon N, Nowson CA. BMI and all-cause mortality in older adults: A meta-analysis. Am J Clin Nutr. 2014;99(4):875–90.
- Brown RE, Kuk JL. Consequences of obesity and weight loss: A devil’s advocate position. Obes Rev. 2015;16(1):77–87.
- Sims EAH. Are there persons who are obese, but metabolically healthy? Metabolism. 2001;50(12):1499–504.
- Sørensen TIA, Rissanen A, Korkeila M, Kaprio J. Intention to lose weight, weight changes, and 18-y mortality in overweight individuals without co-morbidities. PLoS Med. 2005;2(6):0510–20.
- Guo, F., Garvey T. Cardiometabolic Disease Risk in Metabolically Healthy and Unhealthy Obesity: Stability of Metabolic Health Status in Adults. Obesity. 2016;24(2):516–25.
- Antonopoulos AS, Tousoulis D. Themolecularmechanisms of obesity paradox. Cardiovasc Res. 2017;113(9):1074–86.
- Harber MP, Kaminsky LA, Arena R, Blair SN, Franklin BA, Myers J, et al. Impact of Cardiorespiratory Fitness on All-Cause and Disease-Specific Mortality: Advances Since 2009. Prog Cardiovasc Dis [Internet]. 2017;60(1):11–20. Available from: http://dx.doi.org/10.1016/j.pcad.2017.03.001
- Barry VW, Baruth M, Beets MW, Durstine JL, Liu J, Blair SN. Fitness vs. fatness on all-cause mortality: A meta-analysis. Prog Cardiovasc Dis [Internet]. 2014;56(4):382–90. Available from: http://dx.doi.org/10.1016/j.pcad.2013.09.002
- Excellence NI for H and C. Weight management : lifestyle services for o ov verweight or obese adults. 2018;(May 2014).
- Anderson JW, Konz EC, Frederich RC, Wood CL. Long-term weight-loss maintenance : a meta-analysis of. Am J Clin Nutr. 2001;74:579–84.
- NICE. National Institute for Clinical Excellence. Obesity: Identification, assessment and management of overweight and obesity in children young people and adults. Nice [Internet]. 2014;(November 2014):64. Available from: https://www.nice.org.uk/guidance/cg189/resources/obesity-identification-assessment-and-management
- Blackburn G. Effect of Degree of Weight Loss on Health Benefits. Obes Res. 1995;3(2 S):211s-216s.
- Douketis JD, Macie C, Thabane L, Williamson DF. Systematic review of long-term weight loss studies in obese adults: Clinical significance and applicability to clinical practice. Int J Obes. 2005;29(10):1153–67.
- Puhl RM, Heuer CA. Obesity stigma: Important considerations for public health. Am J Public Health. 2010;100(6):1019–28.
- Lissner, L., Odesll, P., D’Aostino, R., Stokes, J., Kreger, B., Belanger, A., Brownell K. Variability of body weight and health outcomes in the framingham population. N Engl J Med [Internet]. 1991;329(14):977–86. Available from: http://content.nejm.org/cgi/content/abstract/329/14/977%5Cnhttp://www.nejm.org/doi/abs/10.1056/NEJM199309303291401
- Matheson EM, King DE, Everett CJ. Healthy lifestyle habits and mortality in overweight and obese individuals. J Am Board Fam Med. 2012;25(1):9–15.
- Tylka TL, Annunziato RA, Burgard D, Daníelsdóttir S, Shuman E, Davis C, et al. The Weight-Inclusive versus Weight-Normative Approach to Health: Evaluating the Evidence for Prioritizing Well-Being over Weight Loss. J Obes. 2014;2014.
- Appel, L., Moor, T., Obarzanek, E., Vollmer, W., Svetkey, L., Sacks, F., Bray, G., Vogt, T., Cutler, J., Windhauser, M., Lin, P., Karanja N. A CLINICAL TRIAL OF THE EFFECTS OF DIETARY PATTERNS ON BLOOD PRESSURE L. N Engl J Med. 1997;336(16):1117–24.
- Wharton C, Nustad JK. Effects of the amount and intensity of exercise on plasma lipoproteins: Editor’s comments. Am J Heal Promot. 2006;20(4):300.
- Sutin AR. Weight discrimination and risk of mortality. 2015;25(3):289–313.
- Papadopoulos S, Brennan L. Correlates of weight stigma in adults with overweight and obesity: A systematic literature review. Obesity. 2015;23(9):1743–60.
- Ashmore JA, Friedman KE, Reichmann SK, Musante GJ. Weight-based stigmatization, psychological distress, & binge eating behavior among obese treatment-seeking adults. Eat Behav. 2008;9(2):203–9.
- Jackson SE, Beeken RJ, Wardle J. Perceived weight discrimination and changes in weight, waist circumference, and weight status. Obesity. 2014;22(12):2485–8.
- Sutin AR, Terracciano A. Perceived Weight Discrimination and Obesity. PLoS One. 2013;8(7):1–4.
- Tsenkova VK, Carr D, Schoeller DA, Ryff CD. Perceived weight discrimination amplifies the link between central adiposity and nondiabetic glycemic control (HbA1c). Ann Behav Med. 2011;41(2):243–51.
- Tomiyama AJ. Associations of weight stigma with cortisol and oxidative stress independent of adiposity. Physiol Behav. 2014;176(3):139–48.
- Wee CW, McCarthy EP, Davis RB, Phillips RS. Screening for cervical and breast cancer: Is obesity an unrecognized barrier to preventive care? Ann Intern Med. 2000;132(9):697–704.
- Vartanian LR, Pinkus RT, Smyth JM. Experiences of weight stigma in everyday life: Implications for health motivation. Stigma Heal. 2018;3(2):85–92.
- Puhl R, Suh Y. Health Consequences of Weight Stigma: Implications for Obesity Prevention and Treatment. Curr Obes Rep. 2015;4(2):182–90.
- Himmelstein MS, Puhl RM, Quinn DM. Weight stigma and health: The mediating role of coping responses. Heal Psychol. 2017;37(2):139–47.
- Levy BR, Pilver CE. Residual stigma: Psychological distress among the formerly overweight. 2013;75(2):297–9.
- Pearl RL, Puhl RM. The distinct effects of internalizing weight bias: An experimental study. Body Image [Internet]. 2016;17:38–42. Available from: http://dx.doi.org/10.1016/j.bodyim.2016.02.002
- O’Brien KS, Latner JD, Puhl RM, Vartanian LR, Giles C, Griva K, et al. The relationship between weight stigma and eating behavior is explained by weight bias internalization and psychological distress. Appetite [Internet]. 2016;102:70–6. Available from: http://dx.doi.org/10.1016/j.appet.2016.02.032
- Pearl RL, Puhl RM. Measuring internalized weight attitudes across body weight categories: Validation of the Modified Weight Bias Internalization Scale. Body Image [Internet]. 2014;11(1):89–92. Available from: http://dx.doi.org/10.1016/j.bodyim.2013.09.005
- Bacon JG, Scheltema KE, Robinson BE. Fat Phobia Scale revisited: the short form Fat phobia scale revisited: the short form. 2014;(March 2001):252–7.
- Foster G., Wadden TA, Makris A., Davidson D, Sanderson R., Allison DB. Primary care physicians’ attitudes about obesity and its treatment. Obes Res [Internet]. 2003;11(10):1168–77. Available from: http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=emed6&NEWS=N&AN=14569041
- Puhl RM, Brownell KD. Psychosocial origins of obesity stigma: Toward changing a powerful and pervasive bias. Obes Rev. 2003;4(4):213–27.
- Speakman JR, Levitsky DA, Allison DB, Bray MS, De Castro JM, Clegg DJ, et al. Set points, settling points and some alternative models: Theoretical options to understand how genes and environments combine to regulate body adiposity. DMM Dis Model Mech. 2011;4(6):733–45.
- Puhl RM, Schwartz MB, Brownell KD. Impact of perceived consensus on stereotypes about obese people: A new approach for reducing bias. Heal Psychol. 2005;24(5):517–25.
- Flint SW, Nobles J, Gately P, Sahota P. Weight stigma and discrimination: a call to the media. Lancet Diabetes Endocrinol [Internet]. 2018;6(3):169–70. Available from: http://dx.doi.org/10.1016/S2213-8587(18)30041-X