Weight stigma I: Context and pervasiveness in healthcare

SPEAKER: In this short talk, we’re going to cover some key recommendations in the literature to enhance weight literacy and reduce weight stigma in health professionals.

So we’re going to begin with looking at the complexity of weight stigma. So we will be aiming to understand the complexity of the causes and manifestation of weight stigma as well as to gain a more nuanced appreciation and understanding of how patients who are overweight might feel in a clinical setting. As well as this, we will look at the importance of using a patient-centred approach and allowing patients to choice whether or not they wish to engage in a weight discussion with you.

So first of all, what is weight stigma? Weight stigma is defined as the discrediting of a person because they are seen as overweight or obese.

This can either be explicit weight stigma where biases against weight are conscious and intentional or implicit stigma where biases are automatically activated and may occur unconsciously. Both these forms of bias predict discrimination. However, implicit attitudes are the hardest to modify. And so often researchers are more interested in implicit than explicit weight stigma. In this module, you’ll have access to an implicit weight stigma test developed by Harvard, which looks at automatic associations that you might have about weight. And it’s very worthwhile to complete that exercise online.

Weight bias or stigma is essentially negative attitudes towards people who are overweight. There’s a plethora of evidence that weight stigma, both implicit and explicit, is highly prevalent amongst health care professionals, including doctors, nurses, physiotherapists, and exercise physiologists. And this is really quite concerning. The reason we need to understand weight stigma and address it in our own context is that perception of weight stigma has significant effects on patients and how they engage with healthcare. Let’s take some time to take in the explicit negative associations towards people who are overweight as reported in health care professionals.

When you look at these terms, you’ll see that these are extremely negative, hurtful things to think about a person. These explicit stigmatised attitudes are widespread in the general public. But it’s even more troublesome to think that these attitudes are so prevalent in the health care profession, for which the mantra is to do no harm. These kind of explicit attitudes are even more likely to be under-reported in health care practitioners given the social context of acknowledging such attitudes. This is one of the reasons why researchers are often more interested in implicit stigma and how it may manifest.

You can see that these kind of attitudes involve stereotyping, prejudice, and discrimination.

Research has shown that health professionals commonly have beliefs around willpower in individuals who are overweight or obese, often believing that patients who are overweight are less disciplined, unmotivated, weak-willed, and that they are to blame for their health and that they are costly to society. These kind of inherent beliefs can manifest in our interactions with patients who have overweight or obesity. Just reflect on these and how much you agree or disagree with these explicit statements. We will come back to explore and unpack why we could develop and hold these beliefs.

So why does weight stigma exist? Stigma does not reside within a characteristic or a stigmatised person. It is produced entirely through social interaction. Stigmatisation is entirely contingent on access to social, economic, and political power that allows the identification of differences and therefore the construction of stereotypes.

For example, having a normal or healthy BMI creates an abnormal.

As health care practitioners, we know that BMI is not an accurate representation of overweight or obesity. But this is not true for the understanding of the wider public. Similarly, the use of models in the media creates a normal. This is why we need to be cautious as health care practitioners, as this identification of normal and abnormal can manifest as an element of stigma if we don’t appreciate the broader complexities that comprise weight regulation and weight management. It’s not just being a health professional that gives us these beliefs.

[INAUDIBLE] that any attitudes or beliefs we have towards weight are a product of our own experience. We live in a society where individual responsibility and self-regulation are upheld as important moral imperatives. And we operate on the belief that individuals have a responsibility for their own health and its presumed effect on societal well-being. So when we think about people with lifestyle diseases such as obesity, they are seen as failing, as they are presumably making harmful choices. And while certain individuals’ own choices do play a role, as health care practitioners, we need to recognise that weight and weight control is extraordinarily complex, both at the level of an individual and in the construct of the society in which we live today.

It’s not so simple to presume weight is 100% controllable for individuals without support. And if we can focus just on individual behaviours, rather than systemic issues, we feed into this.

Now clearly the role of the media is an important one in influencing beliefs of society towards weight. And the so-called obesity crisis is widely covered in Australia, where over 65% of adults are classified as overweight or obese.

As you can see, googling obesity crisis results in over 38 million hits. However, over the past few years, in line with the rest of the world, the narrative and understanding around obesity in Australia is slowly changing.

Mainstream media, such as the Sydney Morning Herald and SBS are translating the research evidence around obesity for the public.

For example, Cochrane reviews repeatedly highlight the limitations of diet and exercise, both in weight loss and also in the maintenance of weight loss. Through this course, you’ll have covered the complex regulatory mechanisms of body weight.

And you will know that the complexity of weight regulation extends well beyond the physiological complexity into the social context in which an individual lives.

This is most commonly framed in the literature within the socioecological framework. This framework recognises the health behaviours required for long term maintenance are influenced by complex social and environmental factors extending beyond interpersonal, organisational, community, and public policy levels. We know an individual’s experience of weight is complex and influenced by many, many different factors. And it’s therefore important that as health care professionals, we respond to overweight and obesity appropriately in a judgement-free and empathetic manner.

To finish up, here is a quick summary of what we’ve covered in this lecture. You’ll remember that weight stigma can either be explicit, so that’s conscious, or implicit, unconscious. Whilst it’s probably not surprising to think that weight stigma exists within the general public, it’s important to acknowledge that a large proportion of health professionals also exhibit weight stigma, particularly around beliefs that patients who have overweight or obesity lack willpower, are lazy, or that they’re to blame for their condition. It’s really important to reflect on your own beliefs and to try to become cognizant of any stigmatised thoughts you might have and the ways that they might manifest into your patient interactions.

Finally, it’s important to remember that weight regulation is incredibly complex and that there are far more factors at play than a person eating too much and moving too little.