Weight bias and stigma
What is weight bias and stigma and what is the impact on health?
Weight bias refers to our own individual attitudes and beliefs about obesity and people living in larger bodies. For example, if we believe that people with obesity (PwO) are lazy or lacking in will power, or unintelligent. These would be our own negative views.
Weight Stigma refers to social stereotypes that are very deeply ingrained within society. Example of stereotypes include – that PwO eat too much and that they don’t do enough exercise, and that they are a burden on society. This type of stigma is pervasive in many settings and institutions, including healthcare, schools, and workplaces.
Discrimination happens when we act on our biases, or because of social stereotypes, and we treat people differently and unfairly.
There are 3 types of weight bias:
Explicit bias is when people have overtly negative views, which are expressed openly. An example is a health care professional (HCP) saying to a colleague that they would rather not care for PwO, as they are not trying hard enough to help themselves.
Overt or explicit bias can be easier to identify and address, but many HCPs hold implicit weight bias, which they are unaware of, but has developed over their lifetime of exposure to other people, healthcare colleagues, and the media. Implicit bias is an automatic response, that happens at an unconscious level, prompting you to have thoughts and feelings about someone or something without being fully aware of it. You can believe at a conscious level that you are not biased, but you may still act unintentionally based on unconscious or implicit bias. Clinicians with implicit bias have been shown to spend less time in consultations with PwO, not investigate symptoms appropriately because they are attributed to the patient’s weight, not offer an appropriate treatment because it is considered less effective, perform less screening for serious diseases, in addition to blaming every symptom or problem on the person’s weight.
A particularly harmful form of weight bias is internalised weight bias (IWB), where negative societal attitudes and stereotypes are internalised and the person holds those negatives beliefs about themselves. When bombarded continually with hurtful messages, stigmatising images, and judgemental comments, it can be difficult to not believe them. The inner self agrees with outside opinions and behaviours and IWB becomes a part of a person’s belief system.
IWB been shown to be strongly associated with adverse psychological effects, such as low mood, depression, low self-esteem, and anxiety, and also physical effects, such as increased blood pressure, cortisol levels and inflammatory markers. There are also associations with unhealthy eating behaviours such as skipping meals and binge eating, being less likely to engage with physical activity, and being more likely to avoid healthcare appointments, including important cancer screening visits.
All of these negative effects combine to mean that experience of weight bias and stigma, and particularly when associated with IWB, contribute to further negative impact on health, as well as weight gain and weight regain.
So the still commonly held view that we should be ‘shaming’ people into losing weight, is completely incorrect and all the scientific evidence supports the contrary view that stigma and shame contribute to weight gain.
Eliminating weight bias and stigma
Bias can be reduced by education and training of individuals, and the social stereotypes and stigma can be addressed with education interventions at institutional and structural levels.
Interventions such as policy change and legislation are required to address discrimination and change the unfair treatment of PwO.
Key components of addressing weight bias and stigma in healthcare settings include:
- Increased understanding that there are some controllable but many non-controllable causes of obesity. Weight bias and stigma are rooted in the misconception that body weight is easy to control. The thinking goes that if we just make changes to diet and exercise, as per the simplistic idea of ‘eat less, move more’, this will automatically result in steady and continuous weight loss. This ignores the complexity of energy balance and weight regulation, with multiple factors influencing body weight, including genetics, epigenetics, the environment, psychosocial factors, and health factors, such as chronic pain, stress and weight promoting-medications.
- Evoking empathy – hearing shared experiences from people living with obesity
- Learning from obesity experts, including peer-modelling, so dietitians hearing from another dietitian with expertise, describing how they approach consultations with PwO (not just what not to do, but what to do ie. alternative non-stigmatising approaches)
- Recognition of obesity as a chronic disease. Most HCPs understand the principles of chronic disease models of care, and obesity management is significantly improved when approached using these principles
- Changing the clinic environment to a safe and welcoming space, where people of all body sizes feel comfortable. This includes appropriate furniture such as waiting room chairs, and equipment, such as weighing scales, blood pressure cuffs, beds, and radiology appliances
- Empowering patients, so they can advocate for equitable and high quality healthcare
Exploring our own bias
We all have biases, as the human brain has a natural tendency to look for patterns and associations when navigating the world.
The first step to reducing weight bias is acknowledging that we may have subconscious or implicit weight bias, and being open to exploring our understanding of obesity and the influences and thinking that we may have absorbed from friends, family, society, colleagues, and institutions over the years.
You may choose to explore if you hold implicit weight bias online – is an example of one of the available implicit tests.
You can read about how your bias may be impacting on clinical care in the ACTION IO research studies. These are global surveys of HCPs and PwO in many different countries, that provide information on ‘misalignment between perception, reality and actions in obesity’. The findings of these studies illustrate how our bias and misunderstanding can contribute barriers to effective healthcare for PwO.
A key finding of the UK study identified that PwO wait an average of 9 years before discussing weight with their HCP. A majority of HCPs reported perception of lack of interest and motivation in losing weight as reasons not to raise the subject of weight with patients. The majority of PwO were interested in losing weight, but did not raise the issue with their HCP as they assumed full responsibility for their own weight loss.
You can read more here.
Public health campaigns for obesity
Stigma is one of the major – if not the major – obstacle to the improvement of care for people with stigmatised illnesses. People living with a stigmatised disease often say that living with the stigma is harder than living with the disease.
Public health campaigns can be effective methods of raising awareness, increasing understanding, and reducing stigma in society.
Unfortunately there are many past examples of so-called ‘shame campaigns’, based on the idea of shaming people into changing behaviour. Research has shown that these types of campaigns are not only not successful, but they can also increase weight bias and stigma, including internalised weight bias, thereby increasing the likelihood of weight gain and adverse health outcomes.
These kinds of campaigns put the focus on personal responsibility, and make the assumption that healthy behaviours will automatically result in weight loss, driven by the simplistic ‘eat less, move more’ narrative. The focus should be on health, not weight, encouraging healthy eating and improved quality of life for people of all shapes and sizes.
We would like to see public health campaigns similar to the kinds of campaigns that were used in the past to reduce stigma for people living with diseases such as HIV or depression. Public Health campaigns for obesity should focus on raising awareness of the complexity of obesity, explaining that it has nothing to do with willpower or discipline, but that it is a chronic disease, and not a choice.
You can read more here
Why is weight stigma pervasive in healthcare?
As clinicians, we pride ourselves on practicing evidence-based medicine, and using evidence-based treatments. Despite a wealth of scientific study confirming obesity is a chronic, relapsing, multifactorial, neurobehavioural disease, there is a prevailing narrative among many clinicians, that focuses on personal responsibility, willpower, and people needing to ‘try harder’. This false narrative believes that losing weight is simple for everyone, it is just a simple equation of energy-in energy-out, eating less and moving more.
However, it is not that simple… It is extremely complex. Over 15 years ago in the UK, the Foresight Obesity System Map detailed just how complex it is to model the multiple and varied factors contributing to energy balance, including individual psychology, socioeconomic, built environment, individual activity, physiology, and food production. You can access and interact with this map.
HCPs do not need to have a full understanding of the complex genetic, biological, social and environmental contributors to dysregulation of energy balance and weight. However, it is important to have some awareness of the complex and mutli-factorial nature of this disease, including an awareness of how the body tightly regulates weight. You can read more about this in ‘key messages‘.
You can read more about weight bias and stigma at the following links:
Please watch the following videos to learn more: