Why the government's new strategy for obesity needs to avoid weight stigma

With the Government expected to publish its latest strategy for obesity in the next week, Dr Adrian Brown RD, Lucy Perrow RD and Dr Stuart W. Flint make the case for why avoiding weight stigma within the communications and delivery of the strategy will be so important.

Weight bias and weight stigma are not new terms, and although evidence of weight stigma in healthcare dates back over 30 years, it is only more recently that it has been discussed at the top table within healthcare and Government. However, challenges remain in addressing the ingrained biases held by many, including those commissioning services and working in healthcare.

COVID-19 has had an unparalleled impact on the entire country, with evidence suggesting an increased risk of severe illness and death for some of the population, including people living with overweight and obesity. UK Prime Minister, Boris Johnson, was hospitalised after contracting COVID-19, which has been suggested as a driving force behind a new government obesity strategy that is about to be released.

There is much anticipation and hope from those working in clinical services and also people living with obesity about what this strategy might achieve. However, there remain concerns that this campaign will focus too much on individual responsibility, not address wider inequalities and contribute to further stigma and discrimination towards people living with obesity.

What is weight stigma and why does the government’s new strategy need to avoid it?

Considerable evidence shows that weight stigma and discrimination is reported by people of all backgrounds and occurs in a wide range of settings including workplaces, schools and healthcare.

The term weight bias and weight stigma are similar but have slightly different meanings. Weight bias involves discrimination towards an individual due to their body weight, while weight stigma involves the negative stereotyping of people based on body weight such as laziness, gluttony or lacking willpower ^(1). This stigma can be internalised by people living with obesity, where they apply the negative weight-based stereotypes to themselves _⁽²⁾.

Weight stigma has now been shown to cause considerable harm including compromised psychosocial wellbeing, depressed mood, increased metabolic risk factors and lower self-esteem. In addition, it has been reported that weight stigma negatively impacts on stress, calorie intake and long term body weight ^(3-8).

Despite this, weight stigma is increasing, particularly among the general population ^(9). Stigmatising attitudes are reported by doctors, nurses and dietitians, with reports of 69% of doctors and 37% of dietitians reporting biased attitudes towards people living with obesity ⁽¹⁰⁾, and these negative attitudes are even found in those specialising in obesity. Indeed, in 2018 the UK’s All-Party Parliamentary Group for Obesity reported that 88% of people living with obesity had experienced stigmatisation as a result of their body size ⁽¹¹⁾. In addition, 42% of people did not feel comfortable discussing their weight with the GP, which supports previous evidence that people avoid accessing healthcare due to the fear of being stigmatised by their healthcare professional.

Obesity is a chronic, complex health condition with multiple factors impacting its development including genetics, psychology, environment and societal. Despite this, a commonly held belief is that weight loss is solely an individual’s responsibility, with previous government campaigns focusing their message on getting people to eat less and exercise more. A primary concern with this new strategy is that it will follow this same message.

Although well meaning, this simplistic approach fails to address the wider social determinants of health including obesity. This has led to an unintended increase of self-blame through moralising health behaviours and internalisation of weight-based stigma ^(12). Therefore, it is essential that this new obesity strategy does not follow suit and addresses the wider determinants of health inequalities that have been overlooked in previous campaigns.

What is the BDA doing at the moment?

On March 4^th, 2020 on World Obesity Day, an international consensus statement was published by a team of experts pledging to eradicate weight stigma ⁽¹³⁾. The statement was signed by over 100 medical and scientific organisations including the British Dietetic Association. Within the pledge the key point centred around treating people living with obesity with dignity and respect, reframing from stereotypical language and images, support educational initiatives to reduce weight bias and preventing discrimination in workplaces, healthcare and access to medication.

The media play a key role within the public’s perception and understanding of obesity, yet UK media portrayal and framing of obesity is stigmatising, derogatory and often disrespectful.

It is key that media and other organisations delivering messages regarding obesity avoid stigmatising and discriminatory framing of obesity. With this in mind, the BDA are in the process of finalising a set of media guidelines. These guidelines will include using first person terminology, avoiding combative language e.g. ‘the war on obesity’, recognising the complexity of obesity and using non-stigmatising images, photographs and videos when reporting on obesity.

What can we do if the new strategy is found to be stigmatising?

We need to actively challenge weight stigma and discrimination in all aspects of society including our workplaces, policy and media. It is unacceptable and should not be tolerated given the substantial evidence that exists to demonstrate the impact of weight stigma and discriminatory experiences.

It is also important that we challenge the simplistic rhetoric around obesity that is juxtapose to the substantial evidence that demonstrates the complexity of obesity. We can improve public understanding of obesity by providing evidence informed information about the wide ranging causes that are both within and outside of an individual’s control.

Conclusion

We are all hoping that the new strategy for obesity addresses the whole system and includes key factors that have been overlooked in previous campaigns. The Government must be bold, and move away from the messages of old. They must address health inequalities and importantly avoid stigmatising the people they purport to help.

References:

1. The Lancet Public Health. Addressing weight stigma. The Lancet Public health. 2019;4(4):e168.
2. Pearl RL, Puhl RM. Weight bias internalization and health: a systematic review. Obesity reviews : an official journal of the International Association for the Study of Obesity. 2018;19(8):1141-63.
3. Himmelstein MS, Incollingo Belsky AC, Tomiyama AJ. The weight of stigma: cortisol reactivity to manipulated weight stigma. Obesity. 2015;23(2):368-74.
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11. All Party Parliamentary Group on Obesity A. The Current Landscape of Obesity Services report from the APPG on Obesity. In: Parliament U, editor. London: All-Party Parliamentary Group on Obesity; 2018.
12. Williams O, Annandale E. Obesity, stigma and reflexive embodiment: Feeling the ‘weight’ of expectation. Health. 2019;0(0):1363459318812007.
13. Rubino F, Puhl RM, Cummings DE, Eckel RH, Ryan DH, Mechanick JI, et al. Joint international consensus statement for ending stigma of obesity. Nat Med. 2020.