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Addressing weight stigma and fatphobia in public health

Public health needs to decouple height and weight

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By Amanda Montgomery, RD, LDN | Collaboratory for Health Justice

Public Health’s focus on “obesity” prevention has increased exponentially within the last few decades,and with it an increase in weight stigma and negative attitudes towards people in larger bodies. In the past decade, weight discrimination has increased by 66 percent, and is one of the only forms of discrimination actively condoned by society (1,2). Decades of research have shown that experiencing weight stigma increases one’s risk for diabetes, heart disease, discrimination, bullying, eating disorders, sedentariness, lifelong discomfort in one’s body and even early death 2,3,18,25,26.

Additionally, “obesity” related public health approaches can be harmful because they are based on limited or poor quality evidence, they focus on preventing one outcome at the expense of another outcome, they lack community engagement and they ignore the root cause of problems4. However, the public health field has not taken a critical look at this research, focusing on the narrative that weight is controllable and a personal responsibility. If the goal is to find the most ethical and effective strategies to achieve optimal public health, there needs to be an alternative to “obesity” and weight-focused approaches and a shift in understanding of weight stigma as a social justice issue.

Our public health goals Heading link

  • Cite weight bias

    Recognize examples of weight bias and weight stigma in public health settings, including public health departments and research.

  • Historical measures of health

    Detail the history and consequences of using body mass index (BMI) and weight as a measure of health.

  • Consequences of stigma

    Describe the adverse consequences of weight stigma on patients’ emotional and physical health.

  • Inclusive strategies

    Develop public health strategies, campaigns and research design that are free from weight bias/stigma and are inclusive of all body types.

  • Accessibility and comfort

    Identify strategies to improve accessibility and comfort for patients in larger bodies within all aspects of public health.

The problems with weight-based approaches to health Heading link

Assumptions about weight don’t connect with real-life health needs.

The focus on body size is rooted in racism

Around 81 percent of societies historically have favored people in larger bodies5. Larger bodies signified wealth and prosperity while thinness signified poverty andweakness. However, this began to change due to racism and eugenics. Charles Darwin and other race scientists created a hierarchy of civilization, placing whitemen on top and people of color, specifically black people, at the bottom, considering them to be “less civilized.” Fatness and differing body characteristics wereused to justify lack of civilization:  fatness used as a marker of “uncivilized behavior” while thinness was “more evolved”. This idea was maintained throughoutthe United States in the 19th and 20th centuries, as a way to justify slavery, racism and classism, and control women through “temperance”. This ideology hasperpetuated Desirability Politics- where thinness and whiteness are given more access to social, political and cultural capital6,7.

The BMI is flawed (and you can’t tell someone’s health by their body size)

The BMI was developed by Adolph Quetelet in the 1830’s, with the goal of finding the “perfect human”5,8. Quetelet was not in the medical field and did notintend for the BMI to be used for medical purposes. His sample population only included white French and Scottish men, thus, the BMI is not representative ofthe entire human population. It rose in popularity in the early 20th century when it was discovered by life insurance companies, who used it to set insurance premiums for their clients5. The company found a relationship between weight and mortality, though the sample included only insurance company clients whoself-reported their heights and weights. Nevertheless, it set off an interest in the use of the BMI as a tool to assess health. The BMI was determined to be the best tool to assess health not for its accuracy, but for its ease of use in medicine and research9. The BMI does not consider health behaviors (e.g. stress,nutrition, physical activity) or body composition (e.g. bone, muscle, and fat mass). Therefore, it does not give an accurate picture of health.

Focusing on weight underdiagnoses thin people and misdiagnoses larger people

A study of 40,420 U.S. adults using National Health and Nutrition Examination Survey (NHANES) data from 2005-2012 looked at health stratified by BMI and found:

  • Nearly half of overweight individuals, 29 percent of obese individuals and 16 percent of obesity type 2/3 individuals were “metabolically” healthy
  • Over 30 percent of normal weight individuals were “metabolically unhealthy”10

If extrapolated to the US population, an estimated 74,936,678 US adults are misclassified as unhealthy or healthy if based on BMI alone. Another analysis ofNHANES data showed that those in the overweight BMI category actually have the greatest longevity out of any BMI group, again contradicting the idea that BMIdirectly indicates health status11,12.

When the medical system uses BMI as a health indicator, it can lead to misdiagnosis for people in larger bodies- with the risk of real medical concerns beingoverlooked as the focus is placed on weight or weight loss. Similarly, people in thinner bodies are often under diagnosed due to an assumption of good health.

Evidence shows that d iets don’t work and weight loss research is problematic

Short term weight loss studies indicate that participants lose ~5-10 percent of their baseline weight13. However, long term studies indicate that regardless of initial weight loss, most people regain that weight after two years, with up to two-thirds of dieters likely to regain more weight than they lost on their diets14. Intentionalweight loss has a 90 percent failure rate5. If it were any other drug, it would never be considered for use.

In addition, much of the weight loss data is flawed with many studies featuring14:

  • High attrition rates (up to 70 percent) that often are not reported
  • Multiple interventions (e.g., diet, exercise, smoking cessation) or rigorous (not realistic) interventions
  • Short study length (many studies only last ~6 months)
  • Errors in data analysis

Much of the obesity research in the U.S. is funded by weight loss and drug companies, such as Weight Watchers and Abbot Laboratories- thus influencing thetypes of studies that are funded and published2.

Risks of food restrictions and eating disorders Heading link

A healthy understanding about weight is essential to healthy relationships with food.

Food restriction is harmful

Food restriction (via intentional weight loss) has detrimental effects on our physiology13,15. Our bodies, designed to keep us alive at any cost, do notunderstand the societal importance of dieting. Rather, our bodies interpret food restriction as starvation, and adapt resiliently to keep us from losingimportant stores. When we restrict food, we weaken our body’s natural hunger and fullness cues, making us more susceptible to outside food cues. In addition, our body’s hormones change in attempt to reduce weight loss, producing more hormones that make us feel hungry and increase our cravings for carbohydrate foods, and less hormones that make us feel full.

Ancel Keys’ Minnesota Starvation Experiment found that men who spent three months on a semi-starvation diet (1700 kcal/day) had15:

  • significant decreases in strength/stamina, body temp, heart rate, sex drive and mental ability
  • Increases in fatigue, irritability, depression and apathy
  • Obsession with food (dreaming/fantasizing about food, reading and talking about food nonstop)

Weight cycling is bad for our health

People who are dieting often experience weight cycling: the repeated loss and regain of weight14. Weight cycling is associated with increased all-causemortality, mortality from cardiovascular disease, risk for heart attack, stroke, diabetes, high blood pressure, and suppressed immune function.

Weight cycling is more commonly seen in people in larger bodies, due to the societal expectations that they lose weight or be “working on their health”16.Despite weight cycling’s detrimental effects on health, it is often not considered as a confounding factor in research that investigates the relationship between body size and health17. Therefore, it is hard to say for certain whether worse health outcomes in larger-bodied people are due to weight itself, ordue to confounders such as weight cycling.

Rates of eating disorders/disordered eating are increasing (and it’s becoming normalized)

Dieting is a strong risk factor for disordered eating and eating disorders (18). Disordered eating differs from an eating disorder in that it does not have adiagnosis. However, both disordered eating and eating disorders can have profound negative effects on mental and physical health.

Disordered eating is defined by characteristics such as (19):

  • Frequent dieting, including fasting, chronic restrained eating, restricting major food groups, bingeing, and/or using vomiting and laxatives
  • Anxiety associated with specific foods or feelings of guilt and shame associated with eating
  • Chronic weight fluctuations
  • Rigid rituals and routines surrounding food and exercise
  • Preoccupation with food, weight and body image that negatively impacts quality of life
  • A feeling of loss of control around food, including compulsive eating habits
  • Using exercise, food restriction, fasting or purging to “make up for bad foods” consumed

68% of Americans have dieted in some form (5). 65% of American women ages 25-45 have disordered eating, and 10% have a diagnosed eating disorder (20).U.S. children are 242 times more likely to have an eating disorder than Type 2 Diabetes, and by age 9, 50% of girls have considered restricting food (18,21).

People of color experience eating disorders such as bulimia and binge eating disorder at higher rates than their white counterparts (22,23), often as amediating factor from experiencing racism or other acculturative stressors (32). However, they are more likely to be underdiagnosed, which can occur due tomisconceptions about who gets eating disorders (24,32). LGBTQ+ individuals also have higher rates compared to cisgender, heterosexual individuals, mostlikely as a way to mediate stressors (20).

Health outcomes Heading link

Weight cannot be examined as a health factor in isolation from overall human health, environmental health factors, social determinants of health and issues of health justice.

Higher weight is not causal to worse health outcomes

Overall, there is a correlation between higher BMI and worse health outcomes, yet this does not imply causation14,17. Research studies exploring this relationship should be assessed not only for quality in terms of study length and attrition length, but also whether they evaluate confounders including weight cycling, weight stigma, and trauma, factors often experienced by folks in larger bodies and which can have considerable impacts on health outcomes.

Weight stigma is harmful to health (and not controlled for in research)

Weight stigma is the discrimination or stereotyping based on a person’s weight. It is reported at rates comparable to racism andis one of the last types of discrimination still condoned and carried out by public health and medical experts2. The incidence of weight stigma has increased by 66 percent with the rise of public health campaigns to end the “obesity epidemic.”18

Examples of weight stigma include:

  • Receiving negative comments or “health concerns” about your weight from anyone, including health care professionals
  • Complimenting someone on their weight loss
  • Receiving poor treatment because of your size or being denied/ required to lose weight because of your size in order toreceive a medical treatment
  • Not having comfortable chairs, airplane seats, etc.

Weight stigma is a risk factor for25,26:

  • Inflammation, stress, and high blood pressure
  • Increased blood sugar and risk of Type 2 Diabetes
  • Depression, anxiety, lower self-esteem, & higher body image dissatisfaction
  • Disordered eating behaviors, eating disorder symptoms, and weight gain

Experiencing weight stigma not only increases one’s risk for negative health outcomes, it also leads to health care avoidance bypeople in larger bodies, increasing the chances that they do not receive preventative care services (e.g. cancer screenings)27.

In children, weight-based bullying is one of the most frequent types of bullying experienced in school26. Often, this type ofteasing is a stressor children will face for years, throughout their childhood and into adulthood. Experiencing weight-based bullying often leads to coping though avoidance of physical activity and increased emotional or binge eating.

When we focus on weight, we’re not being trauma informed

Rates of eating disorders are often higher in people who have experienced trauma or Post Traumatic Stress Disorder (PTSD)28,29. People who have experienced trauma may use food as a safe and secure coping mechanism, both to distance themselves from unsettling thoughts or to reduce their attractiveness as defined within a society that equates thinness with beauty. Assessing the relationship between eating and trauma is essential.

Focusing on weight ignores systemic injustices

Though lifestyle factors such as nutrition and exercise are important, it is essential to note the historical racism and injustices within our current food environment. As presented by Soul Fire Farm33, the U.S. food system is built on stolen land usingstolen labor from Black and Latinx indigenous people. Not only has this created a large scale food apartheid and trauma forpeople indigenous to this land, it has caused a disconnection of indigenous people from their cultural practices and identities.

Public health needs a weight-inclusive approach. Here's why: Heading link

  • Bodies come in all sizes

    Appreciate that bodies come in all different shapes and sizes, and that fat people can be just as healthy as thin people. Remember, you cannot tell someone’s health on the inside by looking at their size on the outside. It is the responsibility of those in public health to create environments for every person to thrive in whatever body they live in.

  • Health at Every Size approach

    Use a Health At Every Size (HAES) approach. When we call for weight loss, we shift blame onto individuals and make health and weight a “personal responsibility,” when often they are the result of uncontrollable genetic or environmental factors4. The HAES approach rests on the evidence that while extremes of weight and health problems are correlated,evidence for the role of factors other than weight in people’s health is stronger.

  • Root causes

    Focus on root causes of health and social determinants of health, to develop long-term, sustainable solutions to improved population health.

  • Health access and justice

    Where possible, work to increase health access, autonomy, and social justice for all individuals along the entire weightspectrum. Trust that people move toward greater health when given access to stigma-free health care and opportunities (e.g., gyms with equipment for people of all sizes; medical facilities that do not weigh patients).

  • Assumptions about behavior

    Weight is not a behavior. Focus on behaviors that impact health, such as eating, movement, stress management, sleep, smoking cessation, etc.

  • Moralizing food

    Don’t moralize foods (e.g., “You need to stop eating X”). Instead, promote eating for pleasure, hunger, satiety and nutrition, instead of weight. Evidence shows that people who eat more intuitively eat more nutritious foods and keep their weight more stable over time18.

  • Mindful movement

    Promote mindful movement focused on what brings people joy and connection, not weight loss. A meta-analysis of 16 studies found that regardless of BMI, mortality indicators improved with exercise, indicating that movement can be healthy without a goal of losing weight31.

  • Weight loss treatment

    Critically evaluate the evidence for weight loss treatments and incorporate sustainable, empirically supported practicesinto prevention and treatment efforts. Call for more research where the evidence is weak or absent4.

  • Facilitate discussion

    Have discussions about fatphobia and weight stigma in your classroom and in your research. Engage students and researchers in critical thought about how to best measure health, without using weight as a marker, and how using weight as a marker of health can be harmful.

Where do we go from here? Heading link

Next steps in building a stronger public health understanding of weight and health.

What language do you use?

The term “obesity” is extremely stigmatizing. Instead, use terms such as “people in larger bodies.”

How does fatphobia show up in your classroom?

  • Replace assignments connecting “obesity” and health or that focus on weight loss.
  • Use weight loss research as a tool to think critically about what counts as good research to use when developing public healthinterventions. Consider: Who is most harmed by the use of BMI? How do racism, capitalism, and the use of BMI intersect?Whatwould it look like to center the dignity, safety, and needs of fat folks in health interventions instead? Instead, have students explore other ways to promote health that are not focused on weight and are inclusive of all communities.
  • Use research that isn’t rooted in fatphobia. Research may be fatphobic if it uses BMI as a marker for health, does not critically assess the role of confounders such as weight stigma, weight cycling, or trauma, has a goal of working to reduce the “obesity epidemic” or regards weight as a personal or moral responsibility.

How does fatphobia show up in your research?

  • Stop using BMI in research or contributing to/funding research that is fatphobic.
  • Consider a broad range of research about the impact of weight on health when forming a research question. Public healthinterventions focused on weight loss are often rooted in shame, rather, use your research to explore interventions that areuplifting for all people and inclusive of all body sizes.
  • Are you using BMI to look for differences in health? Unless you are using weight to dismantle fatphobia, consider using adifferent marker to indicate health.
  • Ensure that you are creating an environment that is safe for fat folks. Do you have equipment like blood pressure cuffs orchairs that are comfortable for people in larger bodies? Are you requiring people to be weighed or report their weight?Consider how these aspects may be harmful or stigmatizing to people in larger bodies. Are you creating situations where fatfolks are able and encouraged to participate in the study?

How does fatphobia show up for you internally?

  • Explore your own internalized fatphobia. What biases do you have towards your family, friends, colleagues or students whohave larger bodies?
  • What types of conversations do you have with your family, friends and colleagues about body size, dieting, or what beinghealthy looks or acts like? Do they prioritize thinness?
  • When you speak about your experience with the BMI or your body, are you looking for reassurance that you’re not fat?
  • If you live in a thin body, consider the privileges this brings. Keep in mind intersectionality, and how other identities such as race and ability may play a role in the oppression of bodies. How can you be a better advocate for people in oppressed bodies?