Next week is Weight Stigma Awareness Week (Sept. 28 to Oct. 2), and if there was ever a year to be aware of the physical and mental health impacts of weight stigma, it’s 2020. There’s so much hand-wringing about the association between “obesity” and elevated COVID-19 risk, despite the fact that there’s no magic wand we can wave to make everyone — including thin people with underlying health conditions — have “average” risk. We need more mask-wearing, less fat-shaming.
When you have prejudiced attitudes and beliefs about weight, and direct them against someone based on their weight, that’s weight stigma. There’s this pervasive idea in our society that if you shame someone enough about their weight, they’ll “do something about it.” But fat cells don’t feel stigma, people do — and shame is not an effective motivator for positive change. Research confirms this.
Instead, weight stigma, especially when someone internalizes that stigma and fat-shames themselves, can harm both physical and mental health. Not only does weight stigma increase the risk of depression and anxiety, but it can cause chronic stress. This stress contributes to higher levels of inflammation and oxidative stress, along with disordered eating behaviors — including comfort eating, yo-yo dieting and possibly eating disorders. People who experience weight stigma often avoid exercise in an attempt to hide their bodies and avoid further stigma. Given what we know about the importance of physical activity in maintaining and improving health for people of all sizes, this is adding insult to injury — all this stress, disordered eating and exercise avoidance increases risk for heart disease and Type 2 diabetes.
Lest you think these health effects are due to weight, not weight stigma, think again. Study after study finds that the negative health effects of weight stigma are over and above any effects that weight itself could have on health, and they happen regardless of actual body size. Someone in the “normal” range on the body mass index (BMI) charts can internalize weight stigma, hating their body because you think it should be smaller and living in fear of gaining weight.
Despite growing research about the negative impact of weight stigma, “concern trolling” — criticism disguised as support or concern — remains a popular pastime. When weight is the subject, it’s often fat-shaming disguised as concern for someone’s health. (“That’s great that you’re comfortable in your body, but what about your health?”) Even is someone in a larger body has lost a “clinically significant” amount of weight, say 5%, they are still in the weight stigma crosshairs. If you weight 300 pounds, losing 15 pounds doesn’t make you thin.
Sometimes, this “concern” stems from good intentions, sometimes it’s simply a screen for bullies to hide behind so they can take offense when they’re called out, but intent ceases to matter when the impact causes harm. Whether it’s a public health campaign or a “concerned” comment on social media, you can’t attack — or wage a war on — “obesity” without attacking people who move through the world in visibly large bodies.
The fallout of this war, these attacks, is perhaps the most evident in health care. Research shows that weight stigma is a significant barrier to getting the kind of preventive health care that can help ward off — or at least detect at an early stage— many of the health conditions that are so often associated with having an “obese” BMI. Patients — especially women — who perceive or directly experience weight stigma from health care providers may cancel or delay appointments and preventive health care screenings, especially if they have gained weight since the previous visit. Specifically, body shame may be a reason that many women avoid screenings for breast, skin and cervical cancers.
Many of my clients are in larger bodies, and I see these effects play out every day. The most egregious case was a client who had expressed concerns to her doctor about dying from cancer shortly before undergoing surgery for that cancer. Her doctor told her that her cancer wouldn’t kill her, but her weight would. When she gained weight during recovery, the shame had prompted her to avoid follow-up care and screenings — as well as the exercise she loves.
I have clients in larger bodies who are thriving despite the pandemic, preparing produce from their CSA boxes and finding creative — and safe — ways to stay active now that their gyms and in-person yoga classes aren’t viable options. Yet they dread going to the doctor. They are tired of being prescribed exercise and referred to commercial weight loss programs without even being asked how they eat, what they do for exercise and how they care for themselves. “It’s like they think I just sit on the couch eating potato chips all day,” one client said to me.
When they decide to find a new doctor — whether out of necessity or because they’re fed up — they ask me if I can recommend a doctor who focuses on healthy behaviors rather than weight. “There are some out there,” I say, “but it’s like finding a needle in a haystack.” (If you’re a Health At Every Size-informed primary care physician in the Seattle area, or know of one, I encourage you to email me.)
In a 2018 paper, “What’s Wrong with the ‘War on Obesity’?” the authors wrote, “In a bitter twist of irony, there is evidence of a direct causal pathway from weight stigma to weight gain, with or without changes in eating behavior as a mediator, which demonstrates that … a fat-hating environment makes people fat.” I propose that we need less hate and more happiness, less shame and more support. It’s past time to #EndWeightHate.