Friday, 23 September 2016

How to lose weight stigma and keep it off

The experience of “being fat” is a demoralising, persistent predicament for millions of people.  Reasons for this include the growing centrality of the physical body in the construction of social identities, difficulty in masking one’s size, widespread negative messages about excess weight and stigma-related maltreatment such as bullying.  Unlike race, gender and sexuality, body size is not a legally protected characteristic covered by the UK’s 2010 Equality Act, meaning there is nothing in law to prohibit someone acting in a discriminating way against a fat individual (Moller & Booker, 2014).  Indeed, it has been described as the last “acceptable” form of bias, with social norms condoning the blatant expression of weight-based prejudice and negative weight-related stereotypes (Nolan & Eshleman, 2016).
Before I continue, it feels appropriate to comment on the terminology I will use in this paper.  Whilst the term ‘fat’ makes some people uncomfortable, it is a term that has been reclaimed by the Fat Acceptance Movement, whose perspectives feel most aligned with my values as a trainee counselling psychologist.  They place terms more synonymous with medical discourse, such as “overweight” or “obese”, in quotation marks and I will do the same, noting that these are levels of fatness delineated by the Body Mass Index (BMI) (Moller & Booker, 2014), which is itself based on a Caucasian body type and does not account for body composition.
This paper will firstly consider the origins and impact of weight stigma, thus legitimizing weight-based discrimination as a social justice issue.  We will then examine the social, political and economic factors surrounding weight-based prejudice.

Origins of weight stigma

People who are deemed fat face discrimination and bias in a range of areas including interpersonal relationships (Black, Sokol, & Vartanian, 2014), employment, education and customer service (Ruggs, Hebl, & Williams, 2015).  Fatness is infused with cultural meaning in all cultures, significantly shaping and reflecting identities and the wider social order (Brewis, Wutich, Falletta-Cowden, & Rodriguez-Soto, 2011). Understanding the issue of being fat and the associated stigma is, however, complex, due to the biopsychosocial and environmental nature of “obesity”. 
Traditionally, personal accountability for eating healthily and exercising regularly has been emphasized as the main determinant of weight status, which has in turn predicted strong beliefs that weight is controllable.  This appears to be linked to the notion that body size reproduces contemporary concerns and anxieties in society and has a central meaning of control.  From this perspective, the fat body represents uncontained desire, uncontrolled impulse and unrestrained hunger, whereas the thin body is seen to reflect psychological stability and self-control over one’s inner state within the context of a culture of consumerism (Ogden, 2010).  These notions are highly problematic, however, in that such beliefs are not only associated with stigmatizing attitudes towards fat people, but also divert attention from other causal factors such as biological elements and environmental influences such as food prices, high availability of junk food, medication side effects, poor health, conflicting messages about healthy eating and marketing that promotes the consumption of unhealthy foods (Pearl & Lebowitz, 2014).  Indeed, a 2007 government report presented over 100 factors involved in obesity, many of which operate at the individual level but are beyond individual control (Moller & Booker, 2014).  This aligns with Weiner’s (1985) attribution theory of stigmas, which postulates that the perceived causes and permanence of a stigmatizing condition will influence affective responses and judgements toward specific people.  In the context of weight stigma, a study by Fardouly and Vartanian (2012) found that individuals who were previously “obese” and had lost weight through diet and exercise were perceived more positively than those who had lost weight through surgery.  This difference is reflective of the notion that surgical patients are less responsible for their weight loss.  When someone who is fat tries to lose weight and fails, however, it reinforces the stereotype that they lack willpower (Foster-Gimbel & Engeln, 2016) even though numerous studies have found sustained weight loss to be both difficult and rare.
Repeated failed attempts to lose weight often elicit shame, a key emotional mechanism in the cyclic obesity/ weight-based stigma (COBWEBS) model (Tomiyama, 2014).  This model typifies weight stigma as a vicious cycle, whereby the stress of weight stigma impacts the targeted individual psychologically (e.g. lowered self-esteem), physiologically (leading people to gain more weight through stress-induced cortisol secretion), or behaviourally (engaging in efforts at coping that encourage eating and weight gain).  This finding is supported by large longitudinal studies which have found that weight stigma actually predicts weight gain over time (Hunger et al., 2015).
Despite these findings, negative attitudes towards fat individuals have been observed in the general population, amongst children, health care practitioners, fat people themselves (Black et al., 2014) and even public health campaigns aimed at reducing obesity.  These are based on the premise that if being “obese” were sufficiently unpleasant, then “obese” people would be prompted to adjust their lifestyle and lose weight, despite the absence of any supporting evidence for this view (Vartanian, Pinkus, & Smyth, 2014). Unfortunately, this perspective is reinforced by the dominant medical discourse which has suggested that finding a ‘remedy’ for fatness is the optimal way of reducing weight stigma, thus once again placing responsibility for reducing the issue on those individuals who are fat (Dickins, Thomas, King, Lewis, & Holland, 2011).  This is not the only area in which fat people have been scapegoated; they have also been blamed for draining National Health Service resources, global warming and the world food crisis (Edwards & Roberts, 2009).  Being excessively fat can have negative implications for health, but it seems the heightened level of concern goes way beyond the risks involved and is more indicative of a cultural phenomenon. 
Accompanying these attitudes are a host of negative stereotypes; fat people are seen as lacking motivation and self-discipline, have inferior personal hygiene, symbolize poor health, have questionable moral values (Dickins et al., 2011) and are socially irresponsible (Black et al., 2014).  Fat people also face discrimination in the form of unfair treatment in daily interactions with others (e.g. being excluded, harassed or rejected) and as structural constraints (e.g. fewer employment or educational opportunities, chairs that do not fit and poorer treatment from healthcare professionals) (Brewis, 2014).

Impact of weight stigma

Whilst excessive fatness is commonly understood as a serious public health challenge, the stigma attached to it also creates considerable suffering.  Weight stigma is now a critical social issue, with body dissatisfaction so common that it is now normative and cultural norms that assign individual responsibility, blame and failure to weight gain (Brewis et al., 2011).  This is consistent with Crandall and Eshleman’s (2003) Justification-Suppression model of prejudice, which proposes that believing that a trait is negative and under personal control increases the likelihood that people will convey prejudice against individuals with such traits. 
Weight stigmatization poses numerous consequences for the physical and emotional well-being of targeted individuals, including risk of anxiety, depression, suicidality, low self-esteem, avoidance of physical activity and health care services and increased risk of weight gain (Gloor & Puhl, 2016).  Weight-related societal pressures have been found to predict extreme (sometimes ineffective or dangerous) weight loss measures, future “overweight” status, binge eating and disordered eating (Foster-Gimbel & Engeln, 2016), body hatred and self-stigma (Dickins et al., 2011).  It has also been shown to lead to social disconnection, not helped by the fact that there are limited places outside of diet clubs for fat people to find support and engage in non-weight-related discussions about their health and wellbeing.  Despite this, many “overweight” people report still attending diet clubs even though they know they are ineffective, in order to meet the public pressure to ‘do something’ about their weight.

Intersectionality can also increase the difficulties individuals face regarding their body size.  For example, gay men report more pressure to be lean than heterosexual men and “overweight” gay men are often seen as inviable romantic partners due to the importance of attractiveness (signified by muscularity and low body fat) in the gay community (Foster-Gimbel & Engeln, 2016).  Feminist scholars, meanwhile, argue that issues surrounding women’s weight must be recognized within the context of a patriarchal society (Rothblum, 2014). This argument is supported by studies indicating that fat women are judged more negatively than fat men (Ogden, 2010) and those on lesbian (Share & Mintz, 2002) and bisexual (Taub, 1999) women, which suggest that a culture not invested in satisfying or attracting men may possess a wider range of acceptable body shapes and sizes.

Sociopolitical and economic influences on weight stigma

Despite efforts by the Fat Acceptance Movement to provide an alternative discourse around obesity, it seems that the stigma felt by fat people may be increasing as the public and medical focus on obesity intensifies (Dickins et al., 2011).  The media is a domain in which weight stigma is particularly prevalent, portraying fat individuals as weak-willed, lazy and self-indulgent (Moller & Booker, 2014).  “Overweight” characters in films, comedies and reality television shows are frequent targets of disparagement humour and stigmatization (Pearl & Lebowitz, 2014).  This aligns with the theory of downward social comparison (Wills, 1981) which predicts that people are likely to compare themselves with those in less respected social positions related to a specific attribute (e.g. body weight), thus experiencing an increase in subjective well-being as a result.  Magazines targeting children and adults of all ages seldom have fat people on their covers, sending the message that being fat is both undesirable and unacceptable.  Indeed, some authors have suggested that stigmatizing obesity may motivate people to lose weight due to the notion that stigma can be a powerful source of social control (Major, Hunger, Bunyan, & Miller, 2014).  However, the growing rates of obesity in the UK and globally demonstrate its resistance to current prevention and treatment efforts, including stigmatization.  A 2012 government report found that 57.2% of women and 66.6% of men in England were “overweight” or “obese” and those figures appear to be rising (Moller & Booker, 2014)
On a political level, statements such as that of former U.S Surgeon General, Richard Carmona, who claimed that the “magnitude of [obesity] will dwarf 9-11 or any other terrorist attempt” (Pace, 2006, p. 1) present obesity as a public health crisis and inevitably exacerbate the fear of being fat.  This is despite the fact that no study has ever proven that losing weight prolongs life.  On the contrary, what the research does show is that those who fall into the “overweight” category actually live longer than “normal” weight people (Bacon, 2008).  Numerous anti-obesity initiatives have been developed by governmental, nongovernmental and commercial stakeholders, including regulation and social marketing initiatives implemented nationwide alongside weight-loss interventions aimed at the individual.  However, despite little evidence to suggest the efficacy of any of these interventions on reducing obesity, few alternatives aimed at improving the overall health of “obese” adults exist outside of the weight-loss arena (Dickins et al., 2011).  Indeed, even the British Psychological Society’s publication, ‘Obesity in the UK: A psychological perspective,(Waumsley, 2011) inadvertently reinforces this issue by emphasizing weight-centric psychological interventions and omitting the issue of weight stigma on the grounds of lack of space.
Economically, there are both causes and consequences of obesity.  The falling prices of high-calorie foods, combined with individuals rationally accepting higher body weights in exchange for other things that they value such as time and money, have certainly played a part.  An increase in sedentary occupations and entertainment options are also factors.  The consequences of obesity, meanwhile, are often divided into direct costs such as increased health care, and indirect costs such as decreased productivity, higher job absenteeism and lower wages for “obese” individuals (particularly women) (Dickins et al., 2011).  However, research illustrates that for those who are “overweight”, exposure to stigmatizing messages about the impact of obesity on a social and economic level not only increases their concerns about being stigmatized, but can also paradoxically have the effect of increasing their calorific food consumption and reduce feelings of self-control when it comes to managing their diet (Major et al., 2014)

Previous research has shown that whereas weight stigma may exacerbate weight gain among those who are already “overweight”, it may deter weight gain amongst those who are not.  This may explain the instinctive draw of stigma as a motivational tool; those who are not “overweight” have difficulty understanding what it is like for those who are and assume stigma will help to bolster other people’s resolve to control their eating since it strengthens their own (Major et al., 2014).  Professionals working in all facets of healthcare should therefore avoid using weight-based stigma as a motivational tool and instead focus on well-being and self-care.   Education is required in order to spread this message and promote public health initiatives such as HAES, thus focusing on improving both psychological and physical well-being without focusing on specific ‘ideal’ weights.    


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