Weight stigma: a public health problem

The history of public health shows a long and well-documented track record of disease stigmatization. Diseases such as cholera, leprosy, tuberculosis, syphilis, and more recently, drug addiction, mental health disorders, and HIV/AIDS, are clear examples. Lessons learned demonstrate that this stigma has only increased the suffering of those affected. Moreover, it has significantly hampered efforts to curb the progression of these diseases and address them appropriately. This fact, widely recognized today, has not yet been applied to the so-called obesity “epidemic.”

Obesity is certainly very prevalent in our society. Its prevalence has almost tripled in recent decades among adults, with an alarming increase in children and adolescents. In Spain, around 40% of adults are overweight and more than 20% are obese . The prevalence of overweight and obesity in children and adolescents is around 20% and 15%, respectively, with slight variations depending on the study. These rates are clearly higher in families with lower incomes and lower levels of education.

Public health campaigns have highlighted the numerous risks of obesity, and its prevention and treatment have become a priority in health plans. However, this problem has typically been addressed through a weight-centric or normative approach. This approach focuses on body weight control to define health and well-being, despite the widespread recognition that obesity is not merely excess weight, but rather an excess and dysfunction of adipose tissue that accumulates in certain parts of the body and can impair health. This focus on weight loss and control, coupled with the importance placed on physical appearance and the thin ideal of beauty in Westernized societies, has not reduced obesity rates or improved the effectiveness of treatments. On the contrary, it has generated undesirable negative effects, most notably the stigmatization of people with obesity.

Relevance and effects of weight stigma

It is important to establish some conceptual distinctions. Weight stigma, also known as fatphobia in social and more colloquial contexts, is the most general concept and refers to the social contempt and denigration of people due to their excess body weight. Although there is also stigma associated with being underweight, weight stigma is generally associated with excess weight and obesity.

Weight stigma increases the risk of obesity and worsens associated problems.

The concept of stigma includes three different and related components: stereotype, prejudice, and discrimination.

• Weight-based stereotypes include generalizations such as that obese people are lazy, gluttonous, lack willpower, are incompetent, unmotivated to improve their health, do not follow medical treatment, and are responsible for their higher body weight.
• Weight-related prejudices consist of assuming these stereotypes and also involve an emotional reaction, often of dislike, rejection, and disgust towards people with obesity.
• Finally, discrimination involves explicit behaviors derived from stereotypes and prejudices, which can manifest as mistreatment (for example, weight-related teasing) or unfair treatment towards overweight or obese people (for example, difficulties in accessing certain jobs, inadequate treatment by health professionals, etc.).

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These components can operate at three different levels:

1. The structural level implies an inequality of opportunity shown by institutions or social structures directly or unintentionally, such as the absence of policies or inadequate policies to address obesity, or the lack of adequate sanitary furniture and equipment in health centers to care for people with obesity.
2. The interpersonal or public level involves maintaining stereotypes and negative attitudes towards people with obesity, which can lead to discriminatory actions against them.
3. Finally, intrapersonal stigma, also called self-stigma or internalized stigma, involves being aware of and agreeing with negative weight-based stereotypes and applying them to oneself, which generates feelings of guilt and self-devaluation. This last type of stigma has the most harmful effects on health and, although it is more common in overweight and obese individuals, it occurs at all weight levels.

Weight stigma is omnipresent in our society and manifests itself in virtually every area of life: work, the education system, sports centers, family life, romantic relationships, the media and, most worryingly, in public health campaigns and among professional health teams.

In Western countries, 60% of adults in weight management programs report experiencing weight-related stigma, and of these, two-thirds experienced it from healthcare professionals. In Spain, the prevalence of weight-related stigma experiences in the general adolescent population exceeds 40%, reaching 96% in obese female adolescents. Within this same group, high levels of internalized stigma reach 80%.

Many public health campaigns and interventions by healthcare professionals have blamed people with obesity, believing this would motivate them to lose weight. However, research has clearly shown that weight stigma, especially when internalized, has a very negative impact on the health of those who experience it in four major areas:

1. Mental health problems , such as symptoms of depression and anxiety, body dissatisfaction, low self-esteem, and an increased risk of suicide in adolescents
2. Alterations in eating behavior , such as increased binge eating, food restriction, emotional eating, food-related guilt, and risk of developing an eating disorder.
3. Social functioning , being a victim of ridicule and facilitating isolation.
4. Physical health and health-related behaviors , contributing to greater weight gain, more difficulty maintaining weight loss, greater physiological stress, alcohol consumption, less physical activity, postponing or avoiding seeking medical attention, and higher mortality.

In short, weight stigma increases the risk of obesity and worsens associated health problems. There is ample evidence that, in adolescents, a vicious cycle develops between obesity and stigma: being overweight leads to experiencing stigma, and experiencing stigma contributes to a greater risk of obesity and a worsening of associated health problems. Therefore, weight stigma, especially when internalized, is currently considered one of the main barriers to an effective approach to obesity and a significant public health problem in itself.

The false belief in individual responsibility, also present among healthcare professionals

What explains the widespread presence of this stigma in our society? The stigma surrounding weight has two fundamental roots. On the one hand, there are Westernized aesthetic ideals that equate thinness and athletic bodies with beauty and success, and consider so-called "non-normative" bodies undesirable. On the other hand, there is the widespread belief that obese people are responsible for their condition . This belief is exemplified by the classic message "eat less, move more," based on stereotypes that portray obese people as lacking willpower and, therefore, to blame for their condition, since they don't make an effort to change, when the change is within their own control. Contrary to this belief, obesity has been recognized in recent years as a complex chronic disease, influenced by a set of interrelated factors, such as biological factors (genetic, hormonal, metabolic), social determinants (low income, education, access to the health system), food marketing, difficulties in accessing opportunities for physical activity, or adverse life experiences, among others.

Unfortunately, negative attitudes toward people with obesity, the misattribution of its causes to individual responsibility, and a weight-centric approach to addressing the problem are quite widespread among healthcare professionals . The title of a recent study on this topic perfectly exemplifies this situation: “This doctor doesn’t know anything about you, but the first thing he tells you is, ‘You have to lose weight.’” A study conducted with various healthcare professionals in Spain shows that negative attitudes toward obesity are widespread within this group. The same is true for misconceptions about the causes and appropriate management of obesity. Approximately 60% believe that obesity could be “cured” with lifestyle changes. A similar percentage believes that the main obstacle to weight loss in these individuals is a lack of motivation, and more than a third believe that the main reason a person with obesity regains lost weight after treatment lies in their diet and lifestyle. Professionals who hold these beliefs exhibit significantly more negative attitudes towards people with obesity than those who recognize, in accordance with the most current scientific evidence, that obesity is a chronic problem, and that difficulties in weight control are due to causes beyond voluntary control, such as biological mechanisms that hinder weight loss or powerful social determinants.

What is worrying about this problem is not only the extent of these attitudes and beliefs, but their negative impact on the decision-making of these professionals and on the quality of care provided to people treated for obesity.

Studies show that these individuals often undergo incomplete physical examinations, screening procedures for potentially serious health problems are reduced, eye contact is minimized, and people with obesity exhibit less trust in healthcare professionals and poorer adherence to treatment recommendations. Indeed, it has been observed that one of the serious consequences of stigma is that people with obesity who internalize it delay or even avoid seeking medical attention when they experience any symptom or discomfort that could indicate a health problem requiring professional care.

A change in narrative to address obesity and stigma

Given this situation, addressing weight stigma is crucial. The World Obesity Federation (WOF) has recently published a position statement highlighting the need to change the narrative surrounding obesity in order to recognize and combat the associated stigma , and for society to begin viewing obesity as an extremely complex problem, not as a moral failing or a consequence of a lack of individual willpower. This will require systemic changes and interventions at various levels.

The European Association of Paediatrics (EPA) provides a series of recommendations for institutions involved in children's healthcare, such as

• Recognize obesity as a chronic disease.
• To train professional health teams on the causes and proper approach to obesity and weight stigma.
• Having adequate facilities and equipment that facilitate access to care.
• Promote sustainable changes towards healthier lifestyles.
• Avoid stigmatizing or weight-focused advertising campaigns.
• Eliminate stigmatizing language and images when referring to children and adolescents with obesity and their families.
• Promote a culture that does not encourage stigma in the media.

There are catalogs of stigma-free images for communicating about obesity, provided by various international organizations, that show pictures of happy people with obesity, in leadership roles, physically active, or eating healthy meals. In addition, there are international recommendations on using person-centered language , such as saying "child with obesity" instead of "obese child."

The EPA also provides specific suggestions for healthcare professionals, including:

• Ask permission to talk about the child's or adolescent's weight before addressing the topic.
• To help the person being cared for and their family understand the complex nature of obesity and the responsibility of the current obesogenic environment.
• To provide a comprehensive evaluation of each child or adolescent at a physical and psychological level.
• Tactfully investigate previous episodes of ridicule, discrimination, or internalization of stigma and address them appropriately.
• Request the participation of the child or adolescent and family in the development of a personalized and sustainable care plan.
• Do not assume that if the weight has not changed, neither have the behaviors.

It appears that new prevention plans, such as the National Strategic Plan for the Reduction of Childhood Obesity (2022-2030) and the new Plan for the Prevention and Management of Childhood Obesity (POICAT) of the Government of Catalonia, address the challenge of changing the narrative, shifting the focus from messages aimed at individual changes to changes in environments and living conditions, and adopting a non-stigmatizing approach. New professional guidelines with this approach are being published, such as the GIRO guide and the HASPO report.

But there is still a long way to go to reverse this situation, and systemic changes at all levels will be necessary. We already have the data and the evidence, and we know that weight stigma is a major public health problem and one of the main barriers to addressing obesity adequately. We know that obesity is a complex chronic problem, which has more to do with excess and dysfunctional adipose tissue than with excess weight. We know that obesity is not due to the voluntary and inappropriate choices of people who eat poorly and are sedentary, but rather to complex biological mechanisms and social determinants that contribute to its development and make it difficult to treat. Therefore, a shift in narrative and paradigm is required, with a focus on improving the environment and living conditions that encourage lifestyle changes, rather than a focus on weight loss. Furthermore, people with obesity deserve more compassionate treatment. It is time to join the change.