Obesity stigma and the fallacy of ‘tough love’
We know that discrimination based on ethnicity, gender, age, sexual orientation, or disability is wrong and harmful. Why do we not feel the same way about weight-based discrimination?
What is weight bias and obesity stigma?
The World Health Organisation (WHO) [1] defines weight bias as negative attitudes towards, and beliefs about others because of their weight. These attitudes manifest in stereotypes and/or prejudice towards people with obesity, i.e., ‘fat people are lazy’.
Weight bias can be internalised where people hold negative beliefs about themselves due to their weight or size, i.e., ‘I must lack willpower because I struggle with my weight’, or ‘If I can’t take care of myself how can I expect anyone else to help me’.
Weight bias can lead to obesity stigma which involves actions against people with obesity that can cause exclusion, marginalisation, and discrimination in a variety of settings including health care, employment, and education, i.e., ‘why should I waste my time trying to help fat people when they can’t be bothered to help themselves’?
Do we have a problem with obesity stigma?
Yes, we do.
In the United States (US), which New Zealand shares many unfortunate health and lifestyle-related statistics with, a study estimated that weight-based discrimination increased by 66% between 1995/96 and 2004/06 to become as, and in some cases more prevalent than race or age-based discrimination.[2]
A study of New Zealand and American university students found that bias towards ‘fat’ targets was significantly stronger than bias towards ‘gay’ or ‘Muslim’ targets.[3]
When investigating patterns of attitudinal change between 2007 and 2016, researchers found that implicit attitudes towards people with obesity worsened, in contrast to attitudes towards people’s sexual orientation, race, skin tone, age, and disability, which either improved or remained constant.[4]
(Implicit attitudes refer to those attitudes and beliefs we hold deeply but are cautious about expressing overtly to others).
In a substantial review of studies into obesity stigma, psychologists Rebecca Puhl and Chelsea Heuer [5] found that:
- Individuals with obesity are highly stigmatised and face multiple forms of prejudice and discrimination because of their weight.
- Weight bias translates into inequities in employment, healthcare, and educational settings, often due to the widespread negative stereotypes that overweight and obese people are lazy, unmotivated, lacking in discipline, less competent, non-compliant, and sloppy.
- The negative stereotypes attached to people with obesity are widespread and rarely challenged in Western society, leaving people with obesity vulnerable to social injustice, unfair treatment, and impaired quality of life due to substantial disadvantages and stigma.
Alarmingly, social psychologist Rupert Brown [6] cites a range of studies showing that children as young as 3 or 5 show clear preferences for ‘normal’ weight as opposed to overweight peers. Brown notes that while children also show preferences for their own gender and ethnic groups, these preferences tend to reduce as children get older, whereas the preferences for ‘normal’ weight peers tends to continue.
It seems that the process of socialisation enables children to learn about, appreciate, and value difference. This is great – but somethings gone horribly wrong with this normal socialisation process as it applies to bodyweight.
Due to the prevalence of weight bias and obesity stigma in society, and the lack of social taboos attached to expressing negative or offensive feelings and attitudes towards people with obesity, children learn that it’s OK to tease and stigmatise others based on their weight.
Indeed, under the moniker of ‘fatism’ weight bias and obesity stigma are referred to as the last socially acceptable form of bias or ‘ism’ in modern society.
The fallacy of tough love
Puhl and Heuer [5] note that there is a common (mis)perception whereby obesity stigma is justified on the grounds that it somehow motivates people to lose weight and adopt healthier behaviours. The underlying logic seems to be ‘if I treat you badly, you’ll figure that you’re at fault and you’ll change your behaviour to stop being treated badly in the future’.
Other than shifting the responsibility for behaviour change exclusively onto those who are struggling with their weight, does this tough love approach have any merit to it?
A longitudinal study following 2944 people in England [7] found that simply experiencing weight-based stigmatisation was associated with a significant increase in bodyweight and waist circumference.
Another longitudinal study followed 6157 people in the US [8] and found that over the duration of the study (2006 – 2010) those who were overweight and experienced weight discrimination were 2.5 times more likely to become obese, and those who were already obese were 3 times more likely to remain obese, than those who didn’t experience such discrimination.
In a discussion of their findings, the authors of the US study reference a growing body of academic literature which links weight bias and obesity stigma with several unhealthy coping behaviours. Specifically, studies have found that:
- Internalising weight-based stereotypes, teasing, and stigmatising experiences are associated with frequent binge eating.
- Overeating is a common emotion-regulation strategy where those who feel the stress of stigmatisation cope with that stress by eating more.
- Individuals who endure stigmatising experiences perceive themselves to be less competent in physical activities. Consequently, they are less willing to exercise and tend to avoid exercising.
- Psychological stress, in particular stress that involves heightened public awareness, triggers the release of the hormone cortisol which impedes the body’s ability to metabolise fat, and is associated with an increased consumption of food, in particular high incentive foods loaded with extra fat and sugar.
Rather than motivating people to adopt healthier behaviours and lose weight, the tough love approach has the opposite effect. This makes far more sense than the faulty logic used to justify obesity stigma.
If you make people feel bad about themselves, or deficient in some way, then of course people will need to find ways to make themselves feel better.
If you exclude social interaction and physical activity as avenues to find pleasure and reward, then finding comfort in food becomes the obvious and most easily accessible reality. And let’s not forget that modern, ultra-processed food is produced to maximise the pleasure that it provides via the addition of vast quantities of sugar, salt, and fat.
Not only does the tough love fallacy fail those who are struggling with their weight, it fails those who want to help. Attributing blame to the individual shortcomings of people with obesity excuses others from developing a better understanding of the true causes of obesity and designing interventions to address those causes.
This is a particular issue of concern in one key sector…
Obesity stigma in healthcare settings – how bad is it?
Contrary to what we might expect, healthcare settings are a significant source of weight bias and obesity stigma. Unfortunately, the concerning examples are plentiful.
Obesity researchers and health professionals attending a national obesity conference were more likely to describe ‘fat’ people as more lazy, stupid, and worthless than ‘thin’ people.[9]
In their review of obesity stigma, Puhl and Heuer [5] cite a study where more than 50% of 620 primary care physicians viewed obese patients as awkward, unattractive, ugly, and noncompliant. A third of this sample further characterised obese patients as weak-willed, sloppy, and lazy. Studies were also cited where physicians reported that heavier patients were; more annoying, a greater waste of their time, and would be less likely to comply with advice or to benefit from counselling.
Despite the commonly held belief that patients with obesity lack motivation to make lifestyle changes and are noncompliant with treatment recommendations, evidence suggests that the physicians beliefs are in fact misguided.
Research has found that patients self-reported level of motivation is significantly higher than the perceptions of physicians.[10] Research also suggests that physicians and patients have different perceptions about the causes of obesity – physicians are more likely to endorse a ‘victim-blaming’ etiology where the individual is deemed responsible for both the cause (eating too much) and the solution (exercising and going on a diet), whereby patients are more likely to attribute causes to biological or socioeconomic factors.[11]
A qualitative study that examined the experience of 76 people trying to lose weight through traditional interventions highlights the gaps between physicians/practitioners and patients/clients. No lack of effort was evident; participants in the study had tried numerous times to lose weight via approaches that included commercial weight loss programmes, popular diets, and even pharmacological aids. While weight was frequently lost on the particular intervention, the inability to sustain weight loss frequently left participants feeling frustrated and angry. The study concluded that the interventions themselves were simply unrealistic, unsustainable, not suited to people’s actual lifestyles, and often focused exclusively on food rather than behaviour.[12]
Rather than developing a better understanding of the etiology of obesity, and therefore how best to treat it, many healthcare practitioners appear to have bought into the blame game. Weight bias and obesity stigma in the crucial healthcare sector is just as rife as it is elsewhere in society.
Puhl and Heuer[5] report similar findings to those from physicians amongst samples of nurses, medical students, psychologists, fitness professionals and dieticians.
Perhaps the most obvious and offensive manifestation of obesity stigma is the made for TV show 'The Biggest Loser’. The title say’s it all really. Throughout each season of the show contestants are effectively bullied into losing vast quantities of weight for the entertainment of the TV viewer.
Contestants are made to follow exhaustive exercise regimes and adhere to extremely low caloric diets. Doctors are required to be in attendance due to extreme physiological demands that are placed on contestants.
In their calorie deprived and exhausted states the contestants are presented with all manner of temptations to resist. Any failure to resist or adhere to the extreme demands are presented as evidence of weakness and fault on behalf of the contestants. Success is presented as evidence of the ability to overcome such innate 'weaknesses'.
The validity of the intervention and approach of the fitness practitioners running the show is never challenged. Hence, regardless of outcome, the show reinforces the beliefs that underpin weight bias and obesity stigma – that obesity is nothing more than a personal failure, resulting from weakness, laziness, non-compliance and ‘sloppiness’.
According to Puhl and Heuer,[5] the tragic consequence of obesity stigma in healthcare settings is that healthcare practitioners tend to spend less time in appointments with, and provide less health education to patients with obesity as opposed to thinner patients.
This reality doesn’t escape the attention of people with obesity, who are more likely to view themselves as less worthy of treatment and a drain on resources. As such, people with obesity are less likely to seek the help of healthcare practitioners. In hindsight, this isn’t very surprising – why would you seek help from someone you think is likely to blame you for the problem you’re struggling with?
How do we combat obesity stigma?
Society in general needs to significantly improve its understanding of obesity.
We all need to realise that obesity does not represent a shortcoming in individuals; it doesn’t signify that a person is lazy, weak-willed, or ‘sloppy’. Obesity isn’t a sign that someone isn’t worthy of help, care, and support. We need to dump these harmful, unhelpful beliefs into the garbage bin of history because, as more and more kiwis become obese, we need to find solutions that help people, rather than exacerbate their problems.
Obesity is a complex problem influenced by several factors; we need to recognise and treat it as such.
The reality is that our food environment has changed dramatically over the past 40-odd years. Biologically, we’re suited to an environment where food was scarce and labour intensive to exploit. We’re simply not suited to the sedentary lifestyles most of us now lead, surrounded by an abundance of cheap, accessible, ultra-processed food.
Psychologically, we’re driven to eat for the pleasure that food and eating provides; historically, this helped us survive. Today our environment requires us to constantly resist the temptations that our biological drives encourage us to pursue. Socially, we like to fit in with others and food is often central to social events where we like to share and show our love through calories – the more the better.
We need to realise that these factors, and more, affect individuals differently. Weight loss interventions that require individuals to ignore their current reality and adopt a generic ‘one-size-fits-all’ approach are indeed unrealistic, unsustainable, and ill-suited to peoples actual lifestyle. Not only will accepting this help to reduce obesity stigma, but it will also help us all to identify and embrace interventions that investigate and address the real drivers of obesity.
References
[1]. World Health Organisation. (2017). Weight bias and obesity stigma: considerations for the WHO European region
[2]. Andreyeva, Puhl, and Brownell. (2008). Changes in perceived weight discrimination among Americans, 1995-1996 through 2004-2006.
[3]. Latner et al. (2008). Weighing obesity stigma: The relative strength of different forms of bias.
[4]. Charlesworth and Banaji. (2019). Patterns of implicit and explicit attitudes: long-term change and stability from 2007 to 2016.
[5]. Puhl and Heuer. (2012). The stigma of obesity: a review and update.
[6]. Brown. (2010). Prejudice: its social psychology. United Kingdom: Wiley-Blackwell. Chapter 5.
[7]. Jackson, Beeken, and Wardle. (2014). Perceived weight discrimination and changes in weight, waist circumference, and weight status.
[8]. Sutin and Terracciano. (2013). Perceived weight discrimination and obesity.
[9]. Tomiyama et al. (2015). Weight bias in 2001 versus 2013: Contradictory attitudes among obesity researchers and health professionals.
[10]. Befort et al. (2006). Weight-related perceptions among patients and physicians: how well do physicians judge patients motivation to lose weight.
[11]. Ogden et al. (2001) General practitioners’ and patients models of obesity: whose problem is it?
[12]. Thomas et al. (2008). They all work when you stick to them: A qualitative investigation of dieting, weight loss, and physical exercise, in obese individuals.