It’s Time to End the Stigma of Obesity

Fitness pros can lead the charge against body-driven bias. But first we have to recognize we are part of the problem.

To people affected by obesity, there may be nothing more stigmatizing than walking through the doors of a fitness center and working with fitness professionals.

Weight stigma, also called weight bias—“the social devaluation and denigration of people perceived to carry excess weight” (Tomiyama 2014)—is so pervasive that it may well be the last form of widespread stigmatization that is still socially acceptable. What’s more, it triggers a vicious cycle of eating more and exercising less, leading to further weight gain (Tomiyama 2014).

People with obesity represent a distinct customer segment for fitness professionals. For this population, as for anyone at risk of chronic disease, we have an obligation to create a welcoming, accepting environment. However, making this happen is much easier said than done.

Weight bias lurks even in the most conscientious health professionals, including obesity medicine specialists (Schwartz et al. 2003). Documenting your own internal biases (see the sidebar “Testing Your Weight Bias”) and understanding the true causes of obesity (see the sidebar “The Complex Causes of Obesity”) are crucial starting points in overcoming weight stigma.

But even if you know about the painful personal effects of obesity stigmatization, a few major questions remain unanswered:

  • How is weight stigma hurting us as a society?
  • What are our mistaken assumptions about obesity?
  • What can fitness professionals do to help overcome hurtful patterns of bias?

Let’s look at each of these questions in more depth:

The Social Costs of Weight Bias

Weight bias increases people’s risk of myriad physical and mental health threats (see Table 1). This bias may be most pronounced in the healthcare system, where many patients with obesity report that they

  • feel disrespected;
  • think they will not be taken seriously;
  • see all their medical problems blamed on weight; and
  • feel reluctant to address their weight with health providers.

Many people with obesity avoid or delay preventive health care because they fear encountering disrespect, negative attitudes, embarrassment when being weighed, unsolicited weight loss advice, and medical equipment too small to accommodate their body size (Phelan et al. 2015).

Things are probably just as bad in the fitness industry. Many people with obesity may arrive at your door expecting to experience bias, and their view of exercise may already be negative (Pearl, Dovidio & Puhl 2015). They may also feel intimidated by or unwelcome in a typical fitness facility, which may not have the appropriate equipment for their body size. Many gym clients and employees are very fit, and they may be judgmental—or may seem judgmental to someone who is carrying extra weight.

To fight these tendencies, fitness pros need to recalibrate their beliefs about obesity.

Testing Our Obesity Assumptions

Weight bias happens mostly because people think obesity reflects lack of willpower and poor choices. Because healthy nutrition and fitness habits can prevent or reduce obesity, people assume it’s universally true that achieving a healthy weight is simply a matter of eating less and moving more. But the scientific evidence paints a more complicated picture:

Assumption: Obesity happens because of factors within our personal control, namely overeating and lack of exercise.

Reality: Obesity happens because of a complex interplay of genetics, biology, food intake and energy expenditure. While personal choices do affect weight, other factors may have more impact on a person’s weight. It is not that personal choices should be ignored when addressing weight; it’s that attention to social and environmental causes is just as important (and sometimes more so) for most people.

Assumption: Behavioral changes, willpower and motivation will cure obesity.

Reality: Obesity can never truly be “cured” (see the sidebar “The Complex Causes of Obesity”). While behavioral changes can help people lose weight and get healthier, many people with obesity will never achieve and maintain an “ideal” body weight. Even so, they may have a healthful metabolic profile and high quality and quantity of life.

Assumption: Telling people that obesity puts them at risk for myriad diseases will motivate them to eat less, exercise more and achieve a healthy weight.

Reality: Inciting fear by emphasizing the risks of obesity is likely to backfire because this approach contributes to “stigma salience”—a strong feeling of being stigmatized. As Nolan & Eshleman (2016) point out, “Randomized controlled designs contribute direct evidence that stigma salience harms rather than helps healthy eating behavior.” Stigma salience decreases self-efficacy and motivation to engage in healthy behaviors, and may degrade self-control and increase risk of binge eating.

Assumption: Obesity causes serious health problems.

Reality: The health profiles of people with obesity vary widely. A person whose body mass index is well above average but who is physically active and has lost 10% of body weight may still be considered “obese”—but may actually be much healthier than a sedentary person of normal weight. Some researchers suggest that much of the pathophysiology of obesity may be due not only to excess weight but also to psychological stress induced by weight stigma (Muennig 2008).

Overcoming Weight Bias

Efforts are underway to increase awareness and help people—especially healthcare professionals and fitness pros—to become more sensitive to their biases and adopt a more empathetic, productive approach to helping people affected by obesity. We can all do this by changing our behaviors, empowering clients and educating colleagues.

Changing Our Behaviors

Empathy is crucial for helping clients to achieve their health and fitness goals. You can build empathy by first becoming aware of your biases and then taking conscious steps to identify with and understand your clients’ feelings and motivations. For example, engage in perspective-taking exercises, putting yourself in the shoes of a client with obesity and imagining how he or she might feel when starting a program with you; learn motivational interviewing; or increase mindfulness and empathy by practicing meditation and breathing exercises before interacting with clients (Phelan et al. 2015). Also, when working with clients, focus more on health-promoting behaviors, such as physical activity and healthful eating, rather than dwelling on weight or numbers on a scale.

Empowering Clients

Empower obese clients by making a concerted effort to help them feel comfortable and welcomed. Here are some strategies to consider:

Establish trust. Work hard to gain the trust of your clients and show them unyielding positive regard and support as they engage in difficult behavioral changes.

Build confidence. Focus on helping clients to develop self-
efficacy (confidence in their ability to succeed)—arguably the most important predictor of whether a person will sustain a behavior change.

Root out stigmatization. Ensure that programs and marketing aimed at helping people to lose or manage weight include positive images and language. Avoid using

  • before-and-after photos of weight loss;
  • the words fat, obesity, diet and exercise; and
  • pictures of people with obesity engaging in “lazy” behaviors, such as watching TV and eating junk food. These images increase “fat phobia” scores in studies and worsen weight bias (Pearl, Dovidio & Puhl 2015).

Instead, use

  • words like overweight, increased BMI, unhealthy weight, healthier weight, eating habits and physical activity; and
  • imagery of positive behaviors, such as people of many sizes engaging in physical activity or choosing fruits and vegetables at the grocery store.

However, be aware that even positive pictures of people with obesity exercising can incite negative reactions. One study found that participants who saw images of exercise responded with low ratings of liking and being comfortable with public exercise (Pearl, Dovidio & Puhl 2015). This further highlights the challenge that fitness professionals face when striving to create a warm, welcoming and enjoyable exercise experience for people affected by obesity.

Recalibrate your focus. Emphasize function and positive health behaviors. Focus less on weight loss, individual responsibility and willpower, and more on creating home, work and school environments that support healthful eating and physical activity.

Help clients to develop coping skills. Introduce clients to mindfulness techniques. Researchers led participants who had completed at least 6 months of a weight loss program through a 1-day mindfulness and acceptance-based workshop to address weight stigma and its associated psychological distress. Three months after finishing the program, participants were experiencing less stigma and psychological distress and enjoying better quality of life than people in the control group (Lillis et al. 2009).

Also, in a research review that examined the efficacy of mindfulness-based exercises designed to help people distinguish between emotional arousal and physical hunger cues, the reviewers concluded that the interventions did reduce the negative effects of weight bias, including binge eating and emotional eating (O’Reilly et al. 2014).

Stand up against negativity. Studies show that even watching shows like The Biggest Loser increases weight bias and negative attitudes toward exercise (Pearl, Dovidio & Puhl 2015). As you become more aware of weight bias, make a point of refusing to engage in weight-shaming and insensitive behaviors. Speak up to educate others to do the same.

Go public. Advocate for efforts to make the healthy choice the easy choice in workplaces, schools and communities. Engage in campaigns to build healthy communities, where physical activity opportunities are numerous and healthful food options are accessible to everyone.

This has been described as a “behavioral justice” approach, which argues that people should be held responsible for engaging in healthful behaviors only if the people have full access to resources needed to engage in those behaviors (e.g., affordable, healthful foods and safe streets and sidewalks) (Puhl & Heuer 2010).

Advocate for people’s rights. Support efforts to protect the rights of people affected by obesity. Weight discrimination in hiring is still allowed by law, except in Michigan and the California cities of San Francisco and Santa Cruz, where body size is included in human-rights ordinances (Puhl & Heuer 2010). For more information on protecting rights, visit the Obesity Action Coalition, a nonprofit representing and advocating for the rights of people with obesity, at www.obesityaction.org.

Educating Colleagues

Health and fitness pros did not get into this line of work to purposefully harm people based on their weight. Quite the contrary! Most of the time, behavior that ultimately does more harm than good stems from faulty assumptions or lack of awareness. Take what you have learned and adopted into your daily practices to help colleagues do the same. For example:

Talk to gatherings. Present at local and national conferences, in your local community, and anywhere else where health and fitness professionals congregate; educate colleagues on the genetic, environmental, biological, psychological and social contributors to weight gain and loss.

Tell people about bias. Increase awareness that bias affects quality of care. Give examples of people with counter-stereotypical traits; for example, describe people with obesity who are intelligent and successful, and who enjoy health-promoting activities (Puhl et al. 2016).

Teach “people-first” language. Avoid using obese people or the obese, which define an entire person by a single factor: weight. It’s fairer to use phrases like people affected by obesity or a person with obesity, because there is more to people than their health conditions and physical size (Kyle & Puhl 2014).

Wrapping It Up

Ultimately, we’re probably all guilty of weight bias, often without even realizing it. Becoming more aware of our biases—and taking firm steps to unlearn them—goes a long way toward turning things around. Overcoming weight stigma may well be the key to helping people with obesity embrace the diet and activities that are most likely to contribute to a long and healthy life. That’s much more vital than any number on a scale.

Table 1: The Consequences of Weight Bias Physical Health

Physical Health

    • increased stress response and inflammation
    • chronic stress (contributes to heart disease, stroke,
    • depression and anxiety disorder)

increased food consumption
decreased physical activity

  • weight gain and more difficulty with weight loss
  • avoidance of health care, and delay in preventive services
  • poorer treatment adherence
    less trust of providers
  • poor communication with healthcare providers
  • poor blood sugar control
  • less effective self-management of chronic disease
  • more advanced and poorly controlled chronic disease
  • lower health-related quality of life

 

Public Health

  • decreased adherence to calls for behavior change
  • decreased self-efficacy
  • social inequalities
  • increased health dis

References

Agerstrom, J., & Rooth, D.O. 2011. The role of automatic obesity stereotypes in real hiring discrimination. Journal of Applied Psychology, 96 (4), 790-805.
Kyle, T.K., & Puhl, R.M. 2014. Putting people first in obesity. Obesity, 22 (5), 1211.
Lillis, J., et al. 2009. Teaching acceptance and mindfulness to improve the lives of the obese: A preliminary test of a theoretical model. Annals of Behavioral Medicine, 37 (1), 58-69.
Muennig, P. 2008. The body politic: The relationship between stigma and disease. BMC Public Health, 8, 128.
Nolan, L.J., & Eshleman, A. 2016. Paved with good intentions: Paradoxical eating responses to weight stigma. Appetite. Epub ahead of print. Accessed Apr. 20, 2016. http://dx.doi.org/10.1016/j.appet.2016.01.027.
O’Reilly, G.A., et al. 2014. Mindfulness-based interventions for obesity-related eating behaviors: A literature review. Obesity Reviews, 15 (6), 453-61.
Pearl, R.L., Dovidio, J.F., & Puhl, R.M. 2015. Visual portrayals of obesity in health media: Promoting exercise without perpetuating weight bias. Health Education Research, 30 (4), 580-90.
Phelan, S.M., et al. 2015. Impact of weight bias and stigma on quality of care and outcomes for patients with obesity. Obesity Reviews, 16 (4), 319-26.
Puhl, R.M., & Brownell, K.D. 2001. Bias, discrimination, and obesity. Obesity Research, 9 (12), 788-805.
Puhl, R.M., & Heuer, C.A. 2010. Obesity stigma: Important considerations for public health. American Journal of Public Health, 100 (6), 1019-28.
Puhl, R.M., et al. 2016. Overcoming weight bias in management of patients with diabetes and obesity. Clinical Diabetes, 34 (1), 44-50.
Puhl, R.M., & Suh, Y. 2015. Health consequences of weight stigma: Implications for obesity prevention and treatment. Current Obesity Reports, 4 (2), 182-90.
Schwartz, M.B., et al. 2003. Weight bias among health professionals specializing in obesity. Obesity Research, 11 (9), 1033-39.
Setchell, J., et al. 2014. Physiotherapists demonstrate weight stigma: A cross-sectional survey of Australian physiotherapists. Journal of Physiotherapy, 60 (3), 157-62.
Tomiyama, A.J. 2014. Weight stigma is stressful: A review of evidence for the cyclic obesity/weight-based stigma model. Appetite, 82 8-15.
Tyrell, J., et al. 2016. Height, body mass index, and socioeconomic status: Mendelian randomization study in UK Biobank. BMJ. doi:10.1136/bmj.i582.

Natalie Digate Muth, MD, MPH, RD

Natalie Digate Muth, MD, MPH, RD

"Natalie Digate Muth, MD, MPH, RDN, FAAP, is a board-certified pediatrician and obesity medicine physician, registered dietitian and health coach. She practices general pediatrics with a focus on healthy family routines, nutrition, physical activity and behavior change in North County, San Diego. She also serves as the senior advisor for healthcare solutions at the American Council on Exercise. Natalie is the author of five books and is committed to helping every child and family thrive. She is a strong advocate for systems and communities that support prevention and wellness across the lifespan, beginning at 9 months of age."

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