Presidential Column

This Stigma of Obesity

 

Linda Batoshuk

Linda Bartoshuk

University of Florida

In the food and health sciences, the medical effects of obesity are well-documented and well-publicized. But, just as obesity may be associated with a variety of health issues, it can also bring a less well-understood effect: stigma and discrimination. In 2005, the battle against obesity stigma got a new champion: The Rudd Center at Yale (http://www.yaleruddcenter.org/ ) founded by APS Fellow Kelly Brownell. A leader in health psychology, Brownell got his PhD in clinical psychology at Rutgers University. He is a member of the Institute of Medicine and was listed among Time Magazine’s “The World’s Most Influential People.” The charge of the Rudd Center is “to reverse the global spread of obesity; to reduce weight bias; and to galvanize community members, public officials, and advocacy groups to achieve positive, lasting change.” The Rudd Center is a beautiful example of psychological science making the world a better place. I asked two of the Rudd Center Faculty to tell me about their work.  Marlene Schwartz (PhD in Psychology from Yale University with Brownell) is the Deputy Director and Rebecca Puhl (PhD in psychology from Yale, also with Brownell) focuses on Weight Stigma Initiatives.

Bartoshuk: How do we define weight stigma?

Puhl:Weight stigma or bias generally refers to negative attitudes toward a person because he or she is overweight or obese, such as the stereotype that obese persons are lazy or lacking in willpower. These stereotypes can be manifested in different ways, leading to prejudice and discrimination. For example, weight stigma can take the form of verbal comments (e.g., name calling, derogatory remarks, being made fun of), physical bullying and aggression (e.g., hitting, kicking, pushing, shoving), relational victimization (e.g., social exclusion, being ignored or avoided, being the target of rumors), and overt discrimination (e.g., not being hired for a job, being denied a promotion, being assigned lower wages because of one’s weight, or being denied admission to college).

Bartoshuk: How common is this problem?

Puhl: Until recently, the prevalence of weight discrimination in the United States was unknown. But we recently studied this question in a nationally representative sample of over 2,000 American adults and compared the prevalence and patterns of weight discrimination with other forms of discrimination (e.g., based on race, gender, age, sexual orientation, etc). We found that weight discrimination was very common, occurring in employment settings virtually as often as race discrimination, and in some cases even more frequently than age or gender discrimination. For women, in fact, we found that weight discrimination was more common than race discrimination (Puhl, Andreyeva, & Brownell, 2008).

We also looked to see how the prevalence rates have changed over the past decade and found that weight discrimination has increased by 66% and is now essentially on par with rates of racial discrimination (Andreyeva, Puhl, & Brownell, 2008). So, many people are being affected. One might think that as obesity rates continue rise, we would see less stigma. But instead, we’re seeing more. It’s getting worse.

Bartoshuk: In what ways are children confronted with stigma?

Puhl: Children who are overweight or obese are especially vulnerable (Puhl & Latner, 2007). Not surprisingly, peers are frequent critics of obese children, and school is a common setting where weight-based teasing and victimization occurs. Research shows that negative attitudes toward obese children begin as early as preschool age, from 3 to 5 years old. Preschoolers report that their overweight peers are mean and less desirable playmates compared to non-overweight children, and they believe that overweight children are mean, stupid, ugly, unhappy, lazy, and have few friends. As children enter elementary school, attitudes become worse, with children reporting that obese peers are ugly, selfish, lazy, stupid, dishonest, socially isolated, and subject to teasing. This problem has become so pervasive that research now shows that future peer victimization can be predicted by a child’s weight (Griffiths, Wolke, Page, & Horwood, 2006).

Bartoshuk: Lynn McAfee’s experience with a school counselor (see sidebar) reminds me of comments made to me by people who seemed to believe that they were being helpful when they pointed out I was overweight (as if I were unaware of the fact).  What are the consequences of such remarks? Do they help?

Puhl: Weight bias can impair psychological well-being with increased vulnerability to depression, anxiety, lower self-esteem, and poor body image (Neumark-Sztainer et al., 2002; Puhl & Latner, 2007). In addition, research shows that obese youth who are victimized by their peers are two to three times more likely to engage in suicidal thoughts and behaviors than overweight children who are not victimized (Eisenberg, Neumark-Sztainer, & Story, 2003). Importantly, many studies control for body weight and body mass index (BMI), which tells us that it is the stigmatizing experience itself, rather than body weight, that is contributing to adverse psychological outcomes.

There are considerable physical health consequences of weight bias. A number of studies have consistently demonstrated that experiencing weight stigma increases the likelihood of engaging in unhealthy eating behaviors (e.g., such as binge eating or maladaptive weight control practices) and lower levels of physical activity, both of which may exacerbate obesity and weight gain (Haines, Neumark-Sztainer, Eisenberg, & Hannan, 2006; Puhl & Heuer, 2009). Recent research has also found that stigmatization is associated with greater caloric intake, higher program attrition, lower energy expenditure, and less weight loss in overweight adults seeking weight loss treatment (Carels et al., 2009).

We have observed similar findings in our own work as well. For example, we surveyed over 2,400 overweight and obese women, and asked them how they coped with weight bias. We found that 79 percent of women reported coping with weight stigma on multiple occasions by eating more food and that 75 percent reported coping by refusing to diet (Puhl & Brownell, 2006). In a similar study, we found that women who internalized weight-based stereotypes were more likely to engage in binge-eating behaviors and that internalization did not predict adoption of weight loss strategies (Puhl, Moss-Racusin, & Schwartz, 2007).

These findings are important because there seems to be a societal perception that stigmatizing obese individuals will somehow provide incentives for them to be healthier or to lose weight. Instead, the research suggests that the opposite is true — it just leads to unhealthy behaviors that can worsen health.

Bartoshuk: What can parents do?

Puhl: Parents who are concerned about their child’s weight face a complex challenge of providing support without being critical or judgmental, but sometimes even the best-intending parents can end up stigmatizing their children. Studies show that parents express negative attitudes and weight-based stereotypes to their children, and that high percentages of overweight youth report being teased and victimized about their weight by family members. So parents need to be aware that they are not immune to negative attitudes.

Schwartz: I think parents need to understand that humiliating your child and making him or her feel ashamed about being overweight is not an effective strategy to promote healthy behavior change. Keep the focus on behaviors — reinforce willingness to try new foods, eating a variety of foods, and invite your child to help you with shopping, cooking, and making food attractive. Having dinner as a family is associated with many benefits for children — one of which is better diet (Schwartz & Fiese, 2008). It is also important to create daily opportunities for your child to be physically active. Many children have very busy schedules, so families must make choices. Continuously look for fun physical activities that your child enjoys; this is critical to promote self-efficacy and positive body image.

Bartoshuk: Some have argued that efforts at obesity prevention could actually lead to exacerbation of eating disorders. What is the evidence?

Schwartz: At this time, there is no evidence that responsible obesity prevention efforts at the policy level have any iatrogenic effects. Eating disorders are serious psychiatric disorders, and the etiology does not include exposure to a healthy food environment (Schwartz & Henderson, 2009). The type of obesity prevention we are promoting at the Rudd Center is focused on changing the environment so that healthier foods are available, affordable, and palatable. Right now, unhealthy foods are more available, affordable, and palatable than healthy foods.

I believe that as eating well becomes more convenient and less cognitively demanding (i.e., you don’t have to constantly read labels and track your intake because you are surrounded by nutrient-dense, low calorie foods instead of calorie-dense, low nutrient foods), the incidence of disordered eating and preoccupation with eating will actually decrease. People don’t realize how frequently they are exposed to in-store advertising, television commercials, and product placement marketing for “binge” foods like fast food and high-sugar, high-salt snacks. If the marketing and availability of these foods decreases, I think people will be less likely to become primed to want these foods and binge eating rates may actually go down.

In our research, we tested whether adolescent concerns about weight and dieting changed when the school adopted a new set of nutrition standards for competitive foods (Schwartz, Novak, & Fiore, 2009). We found that there was no difference between the intervention and control schools. Although rates of concern were high and did increase from one year to the next in the study, there was no differential increase between conditions. We believe that is because when a school adopts a policy, it isn’t something you take personally or feel is a punishment because of your weight. This is quite different than the experience of having a parent tell you can’t have dessert because you weigh too much.

Parents need to take a “policy” approach to the food environment at home. I would recommend setting guidelines for meals and foods to keep in the house based on the philosophy that this is how our family eats. In our culture, people understand that some families follow rules about eating based on religion (e.g., keeping Kosher, not eating meat on Fridays during Lent, etc.)  In a similar vein, I think we need to develop societal respect for the fact that some families are also going to follow rules about eating based on health. These rules may include things like saying that dinner always includes a vegetable, we don’t drink soda, and we are limited to one “treat” food a day (e.g., a sweet dessert or a high-salt snack like chips). These rules must apply to all family members and not be dependent on weight or shape. I cringe when I hear parents say that they know their child has a terrible diet but they don’t worry because “he is so skinny.” A poor diet is no better for a skinny child than an overweight child. I would like the cultural discussion to become about health for everyone, not just decreasing calories among overweight children.

Interesting side note: Some people find it easier to accept that you don’t eat processed meat because of the carbon footprint associated with it than because it is high in calories.

Bartoshuk: What do you see as the Rudd Center’s primary message?

Puhl: A person’s weight says nothing about their intelligence, character, or contributions to society. We need to fight obesity, not obese people. ♦

References

Andreyeva, T., Puhl, R.M., & Brownell, K. D. (2008). Changes in perceived weight discrimination among Americans, 1995-1996 through 2004-2006. Obesity, 16, 1129-1134.

Carels,R.A., Young,K.M., Wott, C.B., Harper, J., Gumble, A., Oehlof, M.W., & Clayton, A.M. (2009). Weight bias and weight loss treatment outcomes in treatment-seeking adults. Annals of Behavioral Medicine, 37, 350-355.

Eisenberg, M.E., Neumark-Sztainer, D., & Story, M. (2003). Associations of weight based teasing and emotional well-being among adolescents. Archives of Pediatric and Adolescent Medicine, 157, 733-738.

Griffiths, L.J., Wolke, D., Page, A.S., & Horwood, J.P. (2006). Obesity and bullying: different effects for boys and girls. Archives of Disease in Childhood, 91, 121-125.

Haines, J., Neumark-Sztainer, D., Eisenberg, M.E., & Hannan, P.J. (2006). Weight teasing and disordered eating behaviors in adolescents: Longitudinal findings from Project EAT (Eating Among Teens). Pediatrics, 117, 209-215.

Neumark-Sztainer, D., Falkner, N., Story, M., Perry, C., Hannan, P.J., & Mulert, S. (2002). Weight-teasing among adolescents: Correlations with weight status and disordered eating behaviors. International Journal of Obesity, 26, 123-131.

Puhl, R.M., Andreyeva, T., & Brownell, K.D. (2008). Perceptions of weight discrimination: Prevalence and comparison to race and gender descrimination in America. International Journal of Obesity, 32, 992-1001.

Puhl, R.M., & Brownell, K.D. (2006). Confronting and coping with weight stigma: An investigation of overweight and obese adults. Obesity, 14, 1802-1815.

Puhl, R.M., & Heuer, C.A. (2009). The stigma of obesity: A review and update. Obesity, 17, 941-964.

Puhl, R.M., & Latner, J. (2007). Obesity, stigma, and the health of the nation’s children. Psychological Bulletin, 133, 557-580.

Puhl, R.M., Moss-Racusin, C., & Schwartz, M.B. (2007). Internalization of weight bias: implications for binge eating and emotional wellbeing. Obesity, 15, 19-23.

Schwartz, M.B., Chambliss, H.O., Brownell, K.D., Blair, S.N., & Billington, C. (2003). Weight bias among health professionals specializing in obesity. Obesity Research, 11, 1033-1039.

Schwartz, M.B. & Fiese, B.H. (2008). Reclaiming the family table: Mealtimes and childhealth and wellbeing. Society for Research in Child Development: Social Policy Report, 22, 3-19.

Schwartz, M.B., & Henderson, K.E. (2009). Does obesity prevention cause eating disorders? Journal of the American Academy of Child and Adolescent Psychiatry, 48, 784-786.

Schwartz, M.B., Novak, S.A. & Fiore, S. (2009). The impact of removing snacks of low nutritional value from middle schools. Health Education and Behavior, 36, 999-1011.

Some years ago I was teaching a Food Behavior course at Yale. I invited activist Lynn McAfee to talk to the class about obesity, especially the prejudice directed against the obese. McAfee weighs about 500 pounds. When she walked into the classroom, her weight was one of the first things the students noticed, but when she walked out they remembered her humanity. The class was electrified. McAfee is a superb lecturer, and her anecdotes brought the stigma of obesity to life. After class, I took McAfee to dinner at one of my favorite restaurants in New Haven. As we talked about her life, I slowly realized that we were getting a lot of attention from other diners. I was experiencing just a bit of the unwanted attention that obese individuals get every day. McAfee got me invited to a weekend gathering sponsored by NAAFA (National Association to Advance Fat Acceptance). Among the stories that really touched me was that of a woman who had not had an OB/GYN exam in over 15 years because she feared the abusive treatment of her gynecologist. This kind of bias even from health professionals is now well documented (e.g., see Schwartz et al., 2003). McAfee’s life experiences turned her into an activist. She has put that activism to very good use as the Director of Medical Advocacy for the Council on Size and Weight Discrimination (CSWD ). She attends meetings at NIH, goes to scientific conferences and continues to raise important issues. I asked her to write about some of the experiences that led to her current activism. – Linda Bartoshuk

An Activist's Story of Stigma

“My grades were terrible in high school. In ninth grade, I made an appointment to talk to my counselor about what I would have to improve to get into college. He sat across the desk from me and explained that even if my grades improved, I would never get into college. In those days, college applications required you to include a picture of yourself. That was how they weeded out people with dark skin, or people who were Jewish-looking, or people who were fat. The admissions office would see I was fat and wouldn’t even look at my application or grades. Instead of being angry at him, I felt ashamed of my stupidity. Of course fat people couldn’t go to college. He didn’t have to justify it with stereotypes, I knew them already. We were stupid, awkward, slow, and had no business being with the smart, beautiful people in college. So I followed the guidance counselor’s advice and went on a diet. I lost 80 pounds by starving myself and taking lots and lots of phentermine, an amphetamine-like drug. The next year when it came time for my visit to the guidance counselor, he noted that my grades had gotten worse, probably because I was finding it impossible to concentrate when taking four times the recommended dose of phentermine — the dose I needed to quell my appetite. The guidance counselor, leering at my breasts, leaned across his desk and said, ‘I think you should plan on moving to a college town and marrying a college boy. You really are very pretty now.’ Part of me died that day. Everywhere I turn, every aspect of my life is covered with layers of prejudice and discrimination that has been pushed down my gullet for so long that it’s eaten into my gut, poisoned every cell of my body, constructing a world inside me that hates my body as much as everyone outside my body seems to hate it. Except...that one tiny little part of me, the spark that I nurture every day, the part of me that knows I don’t deserve to be treated like this. The part of me that knows I’m different, not deviant. The part of me that knows all humans are beautiful.”

- Lynn McAfee

Director of Medical Advocacy

Council on Size and Weight Discrimination

Observer Vol.23, No.5 May/June, 2010

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