Is Weight Bias and Weight Stigma a Public Health Problem?
Megrette Fletcher M.Ed., RDN, CDCES
In 2005, Dianne Neumark-Sztainer asked, "Can we simultaneously work toward the prevention of obesity and eating disorders in children and adolescents?" She noted weight-related issues are not in isolation. Ten years ago, Eric Stice, Ph.D., C. Nathan Marti, Ph.D., and Shelley Durant, B.S. concluded, "There is a growing body of scholarship that acknowledges that these weight-related domains are in fact related: obesity and eating disorders co-occur in individuals and have risk factors in common." (Stice, et al., 2011) What are these commonalities? This post will explore two overarching commonalities - weight bias and stigma.
Weight Stigma is the social sign carried by a person who is a victim of prejudice and weight bias. Weight Bias is caused by a general belief that stigma and shame will motivate people to lose weight or the idea that people fail to lose weight as a result of inadequate self-discipline or insufficient willpower.
Weight stigma and weight bias are conjoined twins. They both live in the world together, and one is always touching the other. Weight bias includes the inclination to form unreasonable judgments based on an individual’s weight. It begins in childhood, and from a public health perspective, higher-weight children are at an increased risk for bias as a result of their weight. They are often the brunt of teasing and/or discrimination. Weight bias is promoted in the media, research, healthcare, schools, and even by parents of higher-weight children. Weight bias also influences educational success and may affect how healthcare is delivered.
What are the Medical Consequences of Weight Bias?
In 2001, research showed health professionals, specifically among healthcare specialists surrounding weight, hold strong implicit negative attitudes about individuals living with a BMI >35 (Teachman and Brownell, 2001). These stigmatizing attitudes are perceived and received by individuals at higher weight and may contribute to the creation of multiple barriers to healthcare utilization (Drury and Louis, 2002). In 2008, multiple researchers noted a 66 percent increase in weight bias in employment, education and healthcare settings (Andreyeva et al., 2008; Puhl and Heuer, 2009). Weight bias poses adverse mental and physical health consequences such as exercise avoidance (Vartanian and Shaprow, 2008), anxiety (Hilbert et al., 2014), low self-esteem (Hilbert et al., 2014) and depression (Hilbert et al., 2014). It also negatively impacts healthcare treatment outcomes (Carels et al., 2009). Those who experienced weight bias had a 1.5 kg/m2 greater BMI compared to those who did not report weight bias (Hansson and Rasmussen, 2014).
In another study, participants who associated their weight with more negative traits (higher weight bias) were more likely to drop out of an 18-week behavioral weight loss program compared to participants who evidenced lower levels of weight bias (Carels et al., 2009). These studies suggest the stigma experienced by higher-weight individuals may impede the adoption and maintenance of healthy behaviors.
Is This a Public Health Problem?
In 2015 S. M. Phelan, D. J. Burgess, M. W. Yeazel, W. L. Hellerstedt, J. M. Griffin, and M. van Ryn wrote a seminal paper that found primary care providers, medical trainees, nurses and other healthcare professionals hold explicit as well as implicit negative opinions about people with a BMI >35. The research found evidence that providers' communication is less patient centered with members of stigmatized racial groups and other stigmatized groups, including patients with higher BMI. (Gudzune et al., 2013). This lack of rapport coupled with the provider's attitudes toward these patients contributes to this disparity (ibid 2015). While these attitudes may be common in society, their subtle impact, known as implicit bias, is associated with lower patient ratings of care.
The combination of implicit and explicit negative weight attitudes may elevate the potential for impaired patient-centered communication, which is associated with a 19 percent higher risk of individuals not following their treatment plan, mistrust and worse patient weight loss, recovery and mental health outcomes (ibid 2015).
The impact of these attitudes includes less time with patients and physicians who may over‐attribute symptoms and problems to weight and fail to refer the patient for diagnostic testing or consider treatment options beyond advising the patient to lose weight. In one study involving medical students, virtual patients with shortness of breath were more likely to receive lifestyle change recommendations if their BMI was >35 (54% vs. 13%) and more likely to receive medication to manage symptoms if they were BMI<25 (23% vs. 5%) (Persky 2011).
The evidence of harm regarding weight bias and weight stigma is not new. As public health professionals, we find ourselves in the awkward position of being both the problem and the solution at the same time. The Association of Diabetes Care and Education Specialists has taken the first steps to untangle weight from health by developing weight bias language guidelines. Like the ADCES7 Self-Care Behaviors™, these updated language guidelines represent an additional tool to help healthcare professionals understand how to shift language to create a more inclusive healthcare space. Access the quick guide for healthcare professionals today, visit DiabetesEducator.org/Language.
Megrette Fletcher is an author and a diabetes care and education specialist. To learn more about the impact of weight bias visit, www.wn4dcsymposium.com.