September-October: Stigmatizing obesity

As a health and wellness coach and a personal fitness professional, I work with people of all shapes and sizes and have learned and continue to learn to recognize any biases I may have and address them.

Weight stigma, also called weight bias ("social devaluation and denigration of people perceived to carry excess weight) is extremely pervasive and unfortunately, still socially acceptable. Whats makes this really distressing is that it triggers vicious cycle of eating more and moving less, leading to unhealthy weight gain (Tomiyama, 2014, Vartanian and Porter, 2014).

Weight bias increases people's risk of physical (increased stress response and inflammation, chronic stress, mistrust towards health care providers, increased food consumption, difficulty with weight loss and further weight gain, etc), mental (binge eating, depression, anxiety, low self-esteem, poor body image, substance abuse, etc), and social (bullying, decreased attention and compassion in healthcare settings, etc) health threats, and it is probably most pronounced in the healthcare system. Many patients report that they feel disrespected, are not taken seriously, see all their medical problems blamed on weight and thus feel reluctant to discuss their weight with health providers. 

I think it is just as bad in the fitness industry, where clients who are overweight or obese may feel intimidated and unwelcome, the facility may not have appropriate equipment for their body size, and fitness trainers may be judgmental.

To fight these tendencies, fitness professionals and health coaches like me, or anyone in the healthcare industry, need to more closely address their biases and beliefs about obesity. Weight bias happens because people often think obesity reflects a lack of willpower and poor choices. People assume that achieving a healthy weight is simply a matter of eating less and moving more. However, there is strong evidence pointing to several interrelated factors that influence weight gain, from the social, cultural and psychological, to genetic, metabolic and hormonal (Girgis, 2016).

 Factors related to obesity

Factors related to obesity

And the research evidence paints a more complicated picture related to our biases:

1. Assumption: Behavioral changes, willpower and motivation will cure obesity. Reality: obesity can never be "cured". While behavioral changes can help with weight loss and getting healthier, many people with obesity find it close to impossible to achieve and maintain an "ideal" body weight. Even so, they may have a healthy metabolic profile and high quality of life.

2. Assumption: Obesity happens because of factors within our control, like overeating and lack of exercise. Reality: Obesity is the outcome of genetics, biology, food intake, and energy expenditure. While personal choices do affect weight, other factors may have more of an impact on weight. Thus, we need to pay as much attention to social and environmental causes as we would to personal choices.

3. Assumption: Telling people that obesity puts them at risk of several diseases will motivate them to eat less, exercise more, and achieve a healthy weight.  Reality: on the contrary, this fear associated with highlighting the health risks of obesity can lead to a feeling of being stigmatized. In fact, this approach of stigmatizing obesity harms rather than helps positive behavior change, it decreases self-worth, and may lower self-control and increase risk of binge-eating.

4. Assumption: Obesity causes serious health problem. Reality: The health profiles of people with obesity vary considerably. A person whose body mass index is well above average but who is physically active and has lost 10% body weight may still be considered obese, but may actually be much healthier than a sedentary person of normal weight. Some researchers suggest that much of the pathophysiology of obesity may be due not only to excess weight but also to psychological stress induced by weight stigma (Muennig, 2008).

So how can people, especially professionals in the healthcare and wellness field, overcome weight biases? Here are some suggestions:

  1. Change our behavior: empathy is crucial for helping clients achieve their health and fitness goals. Build empathy by being more aware of your biases and taking conscious steps to identify with and understand your clients' feelings and motivations. And while working with clients, focus more on health-promoting behaviors such as physical activity and healthful eating, rather than dwelling on weight or numbers on a scale.
  2. Empowering clients: make them feel comfortable and welcomed by establishing trust and building confidence in the clients' ability to succeed (self-worth or self-efficacy is arguably the most important predictor of whether a person will sustain behavior change). 
  3. Use positive images and language to root out stigmatization: avoid using before and after weight loss pictures, words such as fat, obese, diet and exercise, or pictures of overweight people engaged in "lazy" behaviors (watching TV and eating junk food). These images tend to increase "fat phobia" scores in studies and worsen weight bias (Pearl et al, 2015). Instead, use words like overweight, increased BMI, unhealthy weight, healthier weight, eating habits and physical activity.
  4. Introduce clients to mindfulness techniques: research around mindful awareness techniques has shown that when people distinguish between emotional arousal and physical hunger cues, the negative effects of weight bias were reduced, including binge eating and emotional eating (O'Reilly et al, 2014). 

Ultimately, we are all probably guilty of weight bias, often without even realizing it. Becoming more aware of our biases and taking firm steps to unlearn them goes a long way towards turning things around. Overcoming weight stigma may well be the key to helping people with obesity embrace the eating habits and activities that are most likely to contribute to a long and healthy life. That's much more vital than any number on a scale.

REFERENCES:

  1. Tomiyama, A.J. 2014. Weight Stigma is Stressful: A Review of Evidence of the Cyclic Obesity/Weight-based Stigma Model. Appetite, Nov: 8-15.
  2. Vartanian L. and Porter, A. 2015. Weight Stigma and Eating Behavior: A Review of the Literature. Appetite, Volume 102, July 1: 3-15. 
  3. Girgis, L. 2016. Causes of Obesity: It is not just the Calories. March.
  4. Muennig Peter. 2008. The Body Politic: the Relationship between Stigma and Obesity-associated Disease, BMC Public Health, 8:128.
  5. Pearl et al, 2015. Differential effects of Weight Bias Experiences and Internalization on Exercise among Women with Overweight and obesity. Journal of Health Psychology, Dec 20 (12): 1626-32.
  6. O'Reilly et al. 2014. Mindfulness Interventions for Obesity-related Eating Behaviors: A Literature Review. Obesity Review, June 15 (6): 453.61.