Is Weight Stigma Worse Than Obesity? How to Provide More Compassionate Care

According to recent estimates from the Centers for Disease Control and Prevention (CDC), the prevalence of obesity in the United States is 39.8% among adults and 18.5% among youth.¹ As obesity rates continue to rise, healthcare providers have increased efforts to encourage weight loss in patients considered to be overweight in the interest of reducing the harms associated with obesity, including cardiovascular disease, stroke, and diabetes.²

However, emerging evidence suggests that these efforts may also cause harm by promoting weight stigma, which has been defined as “social rejection and devaluation that accrues to those who do not comply with prevailing social norms of adequate body weight and shape,” according to author A. Janet Tomiyama, PhD, of the Department of Psychology at the University of California Los Angeles and director of the UCLA Dieting, Stress, and Health Laboratory and colleagues, in a 2018 review published in BMC Medicine.³ Some research findings suggest that the impact of weight stigma is more harmful than obesity itself.

Harms of weight stigma

A range of studies have reported that weight stigma is associated with an increased risk for negative health outcomes and mortality.⁴ “Most ironically, it actually begets heightened risk of obesity through multiple obesogenic pathways,” explained Dr Tomiyama and colleagues in the review. For example, research has shown that experiences of weight stigma led to increased eating, decreased self-regulation, increased levels of cortisol (an obesogenic hormone), and avoidance of exercise.³ Other results have demonstrated an increased risk for mood and anxiety disorders (2.5-fold) among individuals who felt they had experienced weight-based discrimination.⁵

In addition, weight stigma has been connected with increased mortality rates. In a 2015 study of 18,771 adults, the risk for dying was 60% higher among those who had experienced weight discrimination, independent of body mass index (BMI).⁶ “The underlying mechanisms explaining this relationship, which controls for BMI, may reflect the direct and indirect effects of chronic social stress,” the authors wrote.³ “Biological pathways include dysregulation in metabolic health and inflammation, such as higher C-reactive protein, among individuals who experience weight discrimination.”

Weight stigma common in healthcare settings

Weight stigma is common in healthcare settings, where worse outcomes and lower quality of care have been noted for patients with obesity. A study comprised of 2284 physicians found high levels of explicit and implicit “anti-fat” bias — attitudes that have serious consequences for patients.⁷ Other findings have demonstrated that higher-weight patients are less likely to receive needed examinations, and physicians spend less time with these individuals vs patients with lower BMI.³

Higher-weight patients often report being ignored, mistreated, or denied appropriate medical care in clinical settings, with several studies indicating that higher-weight individuals may avoid seeking care because of the discomfort of stigmatization.³ Among medical students, internalized anti-fat attitudes were associated with higher rates of depressive symptoms and substance abuse in those with a higher BMI.⁸

Current healthcare practices that encourage weight loss emphasize the role of individual responsibility and willpower, with the underlying idea that shaming patients may increase motivation to change health behaviors. “[T]his approach perpetuates stigmatization, as higher-weight individuals already engage in self-blame and feel ashamed of their weight,” Dr Tomiyama and colleagues noted.³

Additionally, physicians may overlook other diagnoses when they focus on obesity treatment. Dr Tomiyama and colleagues described a case in which then-17-year-old Rebecca Hiles was told by multiple physicians to lose weight to improve daily coughing fits and shortness of breath before she finally received a correct diagnosis: lung cancer.⁹

Shifting focus

One alternate approach has been gaining increasing attention as a way to improve health outcomes while minimizing weight stigma: Health at Every Size (HAES), a community that focuses on health-promoting behaviors rather than weight loss. HAES was created by Linda Bacon, PhD, associate nutritionist at the University of California, Davis, and author of the books Body Respect and Health at Every Size.

In randomized controlled trials, HAES was linked with improvements in blood pressure, lipid levels, eating habits, dietary quality, physical activity, body image, and more.¹⁰ HAES has also been found to be more successful in achieving these improvements than weight loss interventions, while avoiding stigmatization.

To learn more about the effects of weight stigma and how clinicians can shift their approach to provide more compassionate care to patients regardless of weight, Medical Bag spoke with Drs Bacon and Tomiyama.

Medical Bag: What is known about the effects of weight stigma on health outcomes, and what are potential mechanisms linking weight stigma with weight gain and adverse health outcomes?

Dr Tomiyama: There are many health outcomes that have been linked to weight stigma. Obesity is one of them, ironically. So is mortality. The question is how weight stigma “gets under the skin” to affect health. Here too, there are many ways. Weight stigma is stressful and can trigger physiologic stress cascades that can harm health. Weight stigma also leads to eating unhealthy foods. Importantly, weight stigma can harm health by making people avoid health care, or by harming the patient-provider relationship and harming care.  

Dr Bacon: It’s clear from decades of research that weight stigma is much more damaging [to a patient’s health] than high weight itself. There are 2 pathways: one is the pathway from stigma and discrimination to a physiologic stress response, such as increasing cortisol release, which in turn increases risks for many of the diseases we blame on high weight. The second less influential pathway is that it increases the likelihood of poor behaviors that contribute to health decrement, like overeating as a stress response.

I’m less interested in commenting on your question linking stigma to weight gain, as I don’t want to participate in the fear of weight gain as a reason to end stigma.

Medical Bag: What are your thoughts about why weight stigma is so prevalent among healthcare providers. What can be done about this?

Dr Tomiyama: Weight stigma is prevalent among all of society, and healthcare providers are part of that society. In addition, sustained weight loss is rare, and healthcare providers often mistakenly place 100% of the blame for that on the patient.  

Dr Bacon: Healthcare providers learn ideas about weight in the same way everyone else does, and these cultural attitudes are reinforced in their training. Unquestioned and mistaken assumptions about fat are built into the cultural landscape and underpin interpretations about data.

Fortunately, an alternative viewpoint is out there, and those facts are available, even if they can be hard to hear over the societal clamor of food fear and body bias. Getting to this information requires tuning out the loud “everyone knows” claims about weight and diet. It means questioning health “experts” who themselves have failed to question.

The evidence demonstrates that fat isn’t the bogeyman it’s made out to be, and that a focus on health habits, rather than weight, accomplishes the very goals collective thinness is supposed to achieve — if it were possible in the first place. And moreover, that social determinants of health — like racism and poverty — play a much, much bigger role in health than health behaviors. Attention to social change will be much more effective at health improvement than lecturing people to get more exercise.

Medical Bag: What are some treatment implications or recommendations for our clinician audience regarding how they can provide more compassionate, less weight-biased care?

Dr Tomiyama: One important thing is to shift the mindset from weight, which is hard to control, to behaviors, which are controllable. So, rather than focusing on the number on the scale, instead talk about eating healthy, moving more, sleeping well, and keeping stress down. And if someone does not show signs of poor health, then there is no need to change that person’s weight. 

Dr Bacon: My recommendations for clinicians in treating larger patients:

• Consider your role in setting a safe environment. It’s well documented that many larger people delay or avoid health care for fear of the stigma they’re going to encounter. Some examples of actions you can take to improve care for larger patients: skip the weight loss lecture, make sure you have large enough and comfortable seats in your waiting area, weigh patients only when relevant to their care, educate yourself about the failures of dieting to improve health, and deconstruct the relationship between weight and health.
• When caring for larger patients, first ask yourself what you would say or do if the patient had the same presenting symptoms but was thinner. Next, return to the larger person in the room and consider adjustments helpful to support that particular person. For example, if a fat person presents with knee problems, consider your recommendations to a thinner person — perhaps stretching and strengthening? (Not weight loss!) Then, consider how best to support a person in their particular body in adopting those practices.

Medical Bag: What should be next steps in this area in terms of research or otherwise?

Dr Tomiyama: In my opinion, the next step is eradicating weight stigma. It’s going to be tough — a recent systematic review and meta-analysis both showed that there simply aren’t effective interventions to lessen anti-fat attitudes.^11,12 We need fresh ideas. 

References

1. Hales CM, Carroll MD, Fryar CD, Ogden CL. Prevalence of obesity among adults and youth: United States, 2015–2016. NCHS data brief, no 288. Published October 2017. Accessed October 23, 2018.
2. Centers for Disease Control and Prevention. Adult Obesity Facts. https://www.cdc.gov/obesity/data/adult.html. Updated August 13, 2018. Accessed October 23, 2018.
3. Tomiyama AJ, Carr D, Granbert EM, et al. How and why weight stigma drives the obesity ‘epidemic’ and harms health. BMC Med. 2018;16:123.
4. Sutin AR, Stephan Y, Luchetti M, Terracciano A. Perceived weight discrimination and C-reactive protein. Obesity. 2014;22(9):1595-1961.
5. Hatzenbuehler ML, Keyes KM, Hasin DS. Associations between perceived weight discrimination and the prevalence of psychiatric disorders in the general population. Obesity. 2009;17(11):2033-2039.
6. Sutin AR, Stephan Y, Terracciano A. Weight discrimination and risk of mortality. Psychol Sci. 2015;26(11):1803-1811.
7. 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):e48448.
8. Phelan SM, Burgess DJ, Puhl RM, et al. The adverse effect of weight stigma on the well-being of medical students with overweight or obesity: findings from a national survey. J Gen Intern Med. 2015;30(9):1251-1258.
9. Dusenbery M. Doctors told her she was just fat. She actually had lung cancer. Cosmopolitan. https://www.cosmopolitan.com/health-fitness/a19608429/medical-fatshaming/. Published April 17, 2018. Accessed October 23, 2018.
10. Bacon L, Aphramor L. Weight science: evaluating the evidence for a paradigm shift. Nutr J. 2011;10(1):9.
11. Lee M, Ata RN, Brannick MT. Malleability of weight-biased attitudes and beliefs: A meta-analysis of weight-bias reduction interventions. Body Image. 2014;11(3):251-259.
12. Daníelsdóttir S, O’Brien KS, Ciao A. Anti-fat prejudice reduction: A review of published studies. Obesity Facts. 2010;3(1):47-58