Jessica L. Lawson, PhD
Clinical Health Psychologist
VA Connecticut Healthcare System- West Haven
Yale School of Medicine
She sat across from me, legs crossed and arms folded protectively around herself, as if to try to hide her body as she shared her experience with me. Gazing down at the floor she explained that she did not want to make a return visit to her medical provider.
“It’s like he only saw my obesity. He blamed my body weight for being the cause of my pain. Blamed me for causing my symptoms.”
Whether unintentional, overt, a passing thought, or a direct comment, most people have been on the giving or receiving end of a weight biased comment. Weight bias is defined as negative beliefs, attitudes, assumptions and judgments towards others specifically because of their weight status. Weight bias can exist towards others across the weight spectrum, however it is prominently manifested and propagated via the socially held stereotypes and discrimination against people with overweight and obesity. Weight bias can also manifest internally, which is called internalized weight bias, and refers to turning these biases inward and accepting them as true parts of oneself, resulting in subsequent self-directed disparagement. Put another way, people who have overweight or obesity accept and endorse the discriminatory and negatively biased weight related labels including being lazy, incompetent, intellectually slow, sloppy, socially inept, and irresponsible (Puhl & Heuer, 2009; Tomiyama et al., 2018). The repercussions of internalizing these beliefs can be significantly detrimental across broad psychological, emotional, and physical domains.
Health psychologists are uniquely positioned at the intersection where the psychological, medical, and psychiatric roads meet. Leveraging this stance allows us an optimal vantage point of both patient level and population level health issues and needs. Thus, health psychologists are in an ideal position to educate others and advocate for action against weight bias. Weight bias is an integral variable to consider in an integrative approach to wellbeing across the whole spectrum of weight-related issues. The clinical vignette I share at the beginning of the commentary represents countless others that I know are happening frequently in my office and in many of my colleagues’ offices across this country. The causes of weight-related diagnoses and disordered eating are complex, multi-factorial and often chronic; thus, our treatment approaches must meet these demands. Simplifying this issue places inadvertent blame on our patients, suggesting they are not “trying hard enough” and serving to minimize weight related disorders and the numerous social, economic and political influences at play that perpetuate weight stigma and biases.
Weight bias has been called the last socially acceptable form of stigma and unfortunately the prevalence remains high and pervasive across educational institutions, medical facilities, employment settings and personal relationships. This socialized stigma against individuals with excess weight, stems from the perception that having overweight or obesity is controllable and the unwarranted belief that obesity is caused exclusively by a lack of self-control and discipline. This biased belief system is inherently blaming and shaming towards those with overweight and obesity. Both externalized weight bias attitudes and internalized weight bias have significant social, psychological, and biological repercussions; rigorous research demonstrates how far reaching these consequences can be. Socially, internalizing weight bias is linked with lower education and occupational attainment and increased social avoidance. Psychologically, it is related to lower self-esteem and increased depression, anxiety, maladaptive eating, and stress. And finally, with this increased stress comes damaging biochemical changes related to chronic innervation of the hypothalamic-pituitary-adrenal (HPA) axis.
Put more simply, we can think of the impetus of weight-based shame as the first step into a cyclic model: external weight bias and blame leads to internalized weight bias and shame. This results in HPA activation and an increase in the stress hormone, cortisol which, in turn, can contribute to an increased desire to eat and disordered eating behaviors such as overeating, emotional eating, loss of control eating or comfort eating. Perception of “diet failure” is linked with increased shame, guilt, and distress and perpetuates this feedback loop with maladaptive eating behaviors. Over time, weight gain is a likely biproduct, returning us to the start of the cycle.
My interest in understanding and neutralizing weight bias comes directly from my work in clinical research on obesity and disordered eating. Individuals with obesity are clearly at risk of being the target of weight bias and those who concomitantly struggle with disordered eating behaviors are even more vulnerable. My work with patients who have undergone bariatric surgery and continue to experience subjective loss of control eating (feeling unable to stop or prevent an episode of eating, regardless of the amount of food consumed) suggests that internalized weight bias is associated with the severity and frequency of disordered eating, psychosocial difficulties, and less weight loss following surgery. These results add to the overall research in this area highlighting the importance of weight bias and the role it plays in perpetuating psychosocial sequalae and hindering weight loss efforts.
The shame cycle clearly does not promote positive behavioral change, but actively damages psychological well-being and hinders progress. Even when the presenting problem is only peripherally weight or eating related, it is vital to consider how weight bias is influencing our patients, interfering with any psychological or medical treatment, or getting in the way across life domains. As advocates against weight bias, we can start with a self-assessment of our own conscious or unconscious weight related bias. One suggestion to gain self-insight could be taking the Harvard Implicit Associate Test for weight bias which is available for free online: https://implicit.harvard.edu/implicit/selectatest.html.
In our position as interdisciplinary collaborators, we are uniquely placed to help change the shame narrative and neutralize the weight biases floating unfiltered through our society. The language we choose, in conversation with our patients, our colleagues and even our own internal thoughts, is vital. People first language rather than condition first language, the person with obesity versus the obese person, immediately re-negotiates the perception of blame. Using less stigmatizing verbiage such as “having overweight”, or “having a higher BMI” as opposed to more stigmatizing language e.g., chubby, morbidly obese, fat or fatness, helps establish and maintain rapport. Actually talking about the multiple factors that can contribute to having overweight, rather than avoiding what can otherwise be a sensitive topic, also re-distributes the perception of blame and brings to light problematic and modifiable lifestyle behaviors that clinicians can help patients address. Listening for self-stigmatizing language and assessing for related psychological symptoms that may stem from or contribute to weight or eating concerns can help guide appropriate referrals and treatment. Making certain that your work space can accommodate all patients and colleagues, by offering a selection of different size chairs for instance, promotes a safe, comfortable, and weight-biased free space in a non-verbal way. By taking a weight-neutral and accepting stance, we check our own biases at the door, help our colleagues do the same and encourage our patients to engage in important health behaviors like getting adequate nutrition, sleep, and physical activity. Our own active awareness naturally reflects empathy and kindness, in turn helping those who struggle with internalized weight bias change the narrative, thus bolstering a more positive body image and appreciation of body capability regardless of weight. Our daily interactions and practices, even on the smallest scale, can shift the needle toward sustainable and large-scale reductions in weight bias.
Puhl, R. M., & Heuer, C. A. (2009). The stigma of obesity: a review and update. Obesity (Silver Spring), 17(5), 941-964. doi:10.1038/oby.2008.636
Tomiyama, A. J., Carr, D., Granberg, E. M., Major, B., Robinson, E., Sutin, A. R., & Brewis, A. (2018). How and why weight stigma drives the obesity ‘epidemic’ and harms health. BMC Med, 16(1), 123. doi:10.1186/s12916-018-1116-5