Obesity stigma and the misdirection of responsibility

Last month in the US, WW (formerly known as Weight Watchers), launched a nutrition and weight loss app aimed at 8- to 17-year-olds called Kurbo. The app uses a traffic light system, nudging children towards consuming 'green light foods' (fruits and vegetables), limiting 'amber light foods' (protein and dairy) and avoiding 'red light foods' (sweets, chocolate etc.). Gary Foster, chief scientific officer at WW told the Huffington Post: 'This isn't a weight loss app. This is an app that teaches in a game-ified, fun, engaging way what are the basics of a healthy eating pattern.' The app has received widespread backlash in the media, with parents across the UK arguing that the focus on weight loss puts children at risk of eating disorders and lifelong body dissatisfaction.

Around a third of children aged 2 to 15 in the UK are already overweight or obese. Children are becoming obese at an earlier age and staying obese for longer. Regardless of how we feel about an 8-year-old logging their fish fingers into an app, weight-based stigma, which emphasises individual responsibility for weight, is still a widely accepted basis for discrimination and humiliation, and is something children are socialised to. Examples are not difficult to find across mainstream and social media. Michael Buerk, in a controversial article for the Radio Times this August, claimed that people of higher weights were 'weak, not ill' and should be refused NHS treatment for their 'poor lifestyle choices'. The article further suggested that the general public should see obesity as a selfless sacrifice: by dying a decade earlier than 'the rest of us', people who are obese are helping to counter the pressures of demographic imbalance, overpopulation and climate change.

In July, Cancer Research UK launched a campaign to raise awareness of the link between obesity and cancer with the word 'obesity' blazoned across giant cigarette packets. By connecting obesity to smoking, the campaign implies that individuals are responsible for their body size (and for any cancers they develop). Despite the fact that those from lower income households have twice the rate of cancer than those in the highest, obesity, not income inequality, was selected as the target for the Cancer Research UK campaign. Critics have suggested the lure of commercial gain through their contract with Slimming World (which has generated more than £13 million since 2013) may be influencing Cancer Research UK's focus on individual choice rather than income inequality.

Kurbo represents an identical paradigm of private corporations profiting from the vulnerability of marginalised groups. If, as a society, we are uncomfortable with an 8-year-old feeling that they are responsible for their weight (perhaps we feel it's the parents' fault?) at what age do we decide they are making a 'choice'? 18? 20? Despite research highlighting that obesity is driven by socioeconomic inequality, children face discrimination well before age 8; by their peers and by the adults responsible for their care. The World Health Organisation cites that school-aged children affected by obesity experience a 63 per cent higher chance of being bullied. Teachers who harbour weight-based attitudes can have lower expectations of students, leading to lower educational outcomes for children and young people with obesity. Rather than a stable source of support, research suggests family members are a main source of victimisation. By the time these children reach adulthood their experience of stigma may have already positioned them at a significant disadvantage. 

In one study, those who had experienced weight discrimination in the previous 12 months were twice as likely to have current mood and anxiety disorder diagnoses and nearly 50 per cent more likely to have a substance use disorder. High proportions of people electing to have weight loss surgery have been found to meet diagnostic criteria for a range of psychiatric disorders including anxiety, depression and post-traumatic stress disorder. Many may be reluctant to disclose these difficulties at assessment for fear of being denied life-saving treatment. One study found that 66 per cent of people going for bariatric surgery had experienced childhood maltreatment. Patients who have lost large amounts of weight often report surprise at how differently they are treated by others, having previously attributed negative interactions to their personality rather than their size. Adults with obesity report stigmatization from health care professionals, resulting in avoidance of potentially life-saving screening and increased all-cause mortality. Women report weight stigma as a reason for delaying or avoiding cervical and breast cancer screenings, citing disrespectful treatment, negative attitudes of providers, and unsolicited advice to lose weight as the main barriers.

Weight-based stigma is increasingly recognised as a mechanism by which social and health inequalities are created and exacerbated. Experience of stigma is stressful. As with other forms of stress, stigma limits our ability to control our behaviours and make planned decisions. Higher weight individuals consume more calories following viewing of weight-biased television clips compared to controls or those of higher weights who had watched neutral material. Stigma also limits motivation to exercise, undermining higher weight individuals' ability to access thin spaces. 

Discrimination on the basis of weight often intersects with discrimination and disadvantage arising from other marginalised characteristics. People who are affected by obesity are much more likely to come from black or ethnic minority backgrounds. They are also more likely to have lower incomes and experience disadvantage in terms of socio-economic power. Weight-based discrimination, racism, and socio-economic disadvantage further restrict people's choices, yet can be used by others to legitimise societal prejudice, subtly re-enforcing 'thin, white' privilege.

Weight-based stigma impacts us all. Numerous studies have demonstrated that the threat-response induced by weight-based stigma and its associated social consequences undermines our self-regulation and executive functioning, and may make us more likely to turn to higher calorie foods for comfort (even for those deemed to be at 'healthy' weights). Common responses to weight-based stigma include refusal to diet, increased food intake and avoidance of exercise. Weight-based stigma also undermines health by fostering social isolation; concerns with rejection threaten existing close relationships and discourage individuals from trying new activities or developing new social bonds. This mechanism may partly explain the limited success rate of individualised behavioural interventions. How can we expect people to believe they can meet the complex demands of a healthy diet and exercise when they have been primed by societal stigma (from childhood, at home, school and elsewhere) to believe they are intellectually inferior, weak-willed and 'unhealthy'?

Alternatives to individual responsibility

The UK Government's Foresight Report states that weight is influenced by over 100 complex and interacting factors including genetics, the built environment and a vast array of psychological and social factors. Given this complexity, it makes little sense for one aspect (individual behaviour) to be foregrounded over all other factors. The present government's position in the 'fight' against childhood obesity emphasises the importance of modifying the food environment and has made strides towards limiting fast-food advertising and introducing levies on sugary drinks. Although the need to address income inequality has been recognised by the government, progress on this front is at a standstill. The government's strategy does not mention mitigating the detrimental impact of weight-based stigma on children and adults. 

In my conversations within a bariatric service, I have been struck by the experiences people recount of neglect, trauma, stigma, bullying and inequality. Some have experienced a difficult parental separation; others have witnessed or experienced trauma. Some have parents who couldn't spend time with them, let alone teach them how to cook. Many were subsequently bullied at school, at work, by strangers, by those closest to them, and as a consequence put on more weight. Some binge eat to cope with difficult emotions; others graze to punctuate the monotony of their daily routine. Some are too afraid to leave the house as a result of their experience of stigma, which include receiving note cards on public transport telling them they are fat, having drinks thrown at them while jogging or having photographs taken of them in front of Cancer Research UK's obesity campaign posters to be shared on social media. Attempts to diet have led to further feelings of unworthiness and shame. Some have asked for psychological help, some have not; often for those who have sought help, the help was not there. If we are to frame obesity as 'a poor lifestyle choice', can we, as a society, truly say we have offered a 'choice' of lifestyles? 

A life-course approach which fosters empowerment at every size, addresses social stigma, and facilitates national access to an appropriate food environment is needed. This would mean addressing weight-based bullying through integration with anti-bullying programmes and teacher training. It is important to offer opportunities to promote body positivity in children and young people beyond issues of weight or sports acumen. We need a shift away from the use of dehumanising and stereotyped imagery and language to depict people living with obesity (e.g., images that disproportionately show the lower body, with or without the face blocked, eating junk food etc). We need to create supportive communities by offering subsidised cookery classes, placing restrictions on fast food outlets, and introducing sanctions to ensure that all communities have access to healthy, affordable food. The Food Foundation published a report which claimed that households with children in the bottom two deciles, earning less than £15,860, would need to spend 42 per cent of their disposable income (after housing) on food to meet the UK Government's Eatwell Guidelines. The cost of healthy food needs to be addressed alongside social inequalities. 

Public Health and healthcare professionals must recognise the damage of simplistic obesity narratives, whilst supporting realistic and sustainable behaviour change in a way which addresses the multiple factors that influence weight. Continued societal ambivalence about one of the last remaining 'acceptable' prejudices needs to be recognised, as these prejudices continue to trap the most disadvantaged in our society in lives of exclusion, judged for the skin they live in.

Alex Bogaardt is a Trainee Clinical Psychologist in London.