To coincide with World Obesity Day on 11 October, and the 2018 focus on weight stigma, Stuart Flint has written for us on why weight stigma and discrimination is a priority, how we all need to look at how we might be contributing to it, and what we might do to change the narrative. 

Why are people with obesity treated differently to other public health?

“Weight stigma is defined as the social devaluation and denigration of people perceived to carry excess weight and leads to prejudice, negative stereotyping and discrimination toward those people” (Tomiyama, 2014, p.8)

For many public health concerns such as cancer, there is an appreciation and agreement that we should not stigmatise (e.g. stereotypes, use inappropriate terminology) or discriminate (e.g. bullying, being overlooked for work) towards people with those health concerns. For instance, rarely would people with cancer, mental health concerns or HIV/AIDS be stigmatised or discriminated in the media - so why is obesity different? People with obesity are, almost on a daily basis, stigmatised and experience discrimination across many settings. Yet the determinants of obesity and cancer are the same (e.g. genetic, environmental). Experiences of weight stigma and discrimination have a negative impact on health including but not limited to depression, anxiety, low self-esteem, body image concerns, binge eating, and avoidance of healthcare.

Research would suggest that part of the reason is the belief (reinforced by media, policy etc.) that obesity is controllable and that individuals are responsible for their ‘weight status’, whilst other health conditions are offered greater appreciation of the uncontrollable factors that contribute to their existence. Evidence tells us that obesity is not simple and for the vast majority of people, cannot be changed rapidly. 

So why do the public receive a distorted message? Why is there an obsession with blame and simple solutions to complex public health challenges? 

Some might want a quick fix but blame and unrealistic expectations juxtaposed to the evidence base will only exacerbate negative attitudes and behaviour both for people experiencing health concerns (e.g. lowered self-esteem and self-worth) and others (e.g. perceptions of lack of effort and stigma). 

Irrespective of whether or how much a health concern is controllable or not, people should not be stigmatised or experience discrimination. We should never accept stigma or discrimination towards people based on their health status. As such, I believe that health status should be a protected characteristic. 

When communicating feeds stigma

No matter the topic, if we want to influence and engage people, we must communicate in an appropriate manner. Problematic framing of obesity, inaccurate information, and use of inappropriate language and terminology can be detrimental and needs to be removed from the narrative around body size and ‘weight status’. Whilst this is common and more needs to be done to prohibit stigmatising and discriminatory behaviour, if a child is called “tubby” or “fatty” in a school or education centre, there are repercussions for the culprit. Supporting this, the UK Government stipulates that “By law, all state (not private) schools must have a behaviour policy in place that includes measures to prevent all forms of bullying among pupils,” with similar measures in place for workplaces. 

So why is it acceptable and there are no repercussions for the media to behave in this manner (See image, Ate for Work, The Sun/McDermott, 2018)? How can we expect children and adults not to notice the pervasive weight stigma in media, and, where these messages are consistent, not internalise and possibly endorse these attitudes and beliefs? 

Following the publication of ‘a call to the media’ in The Lancet, several organisations supported a letter sent to the UK’s National Union of Journalist to work collaboratively in reducing the stigmatising portrayal of obesity observed in UK media. In many instances, journalists are not adhering to the codes of conduct of their professional society. This letter has now been published on the All-Party Parliamentary Group on Obesity (UK) website. On the 19^thSeptember 2018, the National Union of Journalists responded, indicating that the letter and our request to work collaboratively to improve media portrayal of obesity will be discussed at their next ethics meeting. 

Non-stigmatising healthcare for all

Meanwhile, inappropriate and insensitive language from healthcare professionals continues to be reported by patients, and is unacceptable, particularly given the likely feelings of vulnerability in such settings.  

Disappointingly, as highlighted in an All Party Parliamentary Group on obesity (UK) report earlier this year, people with obesity experience stigma and discrimination in healthcare settings. For instance, only “26% of people with obesity reported being treated with dignity and respect by healthcare professionals when seeking advice or treatment for their obesity”, and that “42% of people with obesity do not feel comfortable speaking with their GP about their obesity”. The public and patients should be able to attend healthcare settings without fear of being judged, mistreated, stigmatised or discriminated against through lack of advice and where relevant, access to treatment. 

As recommended in the Marmot Report (2010) – “Fair society, healthy lives” - public health should be fair and just. In alignment with the Marmot Report, I would not want to be in a situation where I feel I have not been treated fairly akin to the other people and patients, and I hope and expect that where needed, I would receive evidence based advice and treatment to improve my health status. Is that not what we all want and expect?

When good intentions have unintended consequences

Likewise, the best policy, campaign, or intervention can be designed, but its effectiveness will be reduced if the message or information is inaccessible or inappropriate. It is also likely to have a counterproductive effect. Evidence has accumulated on the impacts of weight stigma and discrimination, informing us that these experiences lead to maladaptive responses and may exacerbate physical and mental health concerns including eating disorders and depression. Thus, it is unacceptable to continue being ignorant of weight stigma and discrimination.

For policy and campaign makers, accurate, fair and non-stigmatising messages are paramount, or else these good intentions can be comprised, lead to public upset, disengagement, and an overall dilution of what they had hoped to achieve. It might also counterproductively perpetuate stigmatising attitudes and behaviours. Oversimplified and abbreviated messages, akin to how media frame headlines to capture attention, or social media users ‘say it in a tweet’, risks removing nuanced details that underplay the complex array of controllable and uncontrollable factors to which obesity and NCDs like cancer, can be attributed. Most effective communications are mindful that people-first language matters, as does factual accuracy. This more sensitive and considered approach reduces the likelihood of public dissatisfaction, media miscommunication, and achievement of the objectives. Campaigns that are inaccurate or insensitive have reduced health promoting efficacy, inciting stigma and in some cases counterproductive. They can also lead to negative perceptions of health promoting organisations. Further negativity around public health campaigns can be compounded by stigmatising images, language and stereotypes within associated media – reinforcing the importance of policy and campaign makers getting the message right in the first place. 

How can organisations, workplaces, Governments, media, individuals do better?

Media: In my opinion, the media are key to reducing weight stigma and discrimination in our society. Media portrayal of obesity contributes to the formation and maintenance of weight stigma attitudes, misconceptions about obesity and influence discriminatory behaviour. Likewise, there are substantial examples of stigmatising comments from Government, healthcare professionals, and academics when working with the media. Thus, when engaging with the media, there is a need for us all to consider how we communicate about obesity, avoiding stigma and discrimination. 

Consult and work with patients and public: Public health has an impact throughout society. We (academics, health professionals, Government, media etc.) should consult and work with people with obesity. Across all of these levels we can follow the National Institute for Health Research (NIHR) and INVOLVE directive that we work ‘with’ patients or public. There are several obesity charities across the world (e.g., Helping Overcome Obesity Problems (UK), Obesity Action Coalition (USA), Obesity Australia (Australia)) that are willing to be consulted and would welcome collaborative opportunities.  

Review current practice and protocol: Weight stigma and discrimination is ingrained in our society, and thus, stigmatising practices might be evident within organisations or methods of delivery. It is important to acknowledge and improve practice, and thus where necessary, remove weight stigma and discrimination that is pervasive in our society today. Healthcare professionals and organisations need to show leadership, improve education and raise awareness about weight stigma and discrimination. We should also support and encourage people and patients to challenge occurrences that they experience or observe. 

Use non-stigmatising language:Several terms are used to refer to obesity, which in many instances carry an emotional response, and may lead to shame, embarrassment and avoidance of healthcare. Rather than using ‘obesity’ or ‘overweight’ as adjectives, person first language is recommended. Use phrasing such as ‘people with obesity’ or ‘adults with obesity’ rather than ‘overweight people’. People first language is an accepted way to address people with physical or mental health conditions, disabilities or chronic illnesses. However, when working with people or patients, take the opportunity to ask what terms are preferred when talking about weight.

Use non-stigmatising images:Media, organisations, government, workplaces and education, should make the most of non-stigmatising image banks when images of people with obesity are needed (see list of non-stigmatising image banks below). 

Can weight stigma interventions can be effective?

If we are serious about reducing weight stigma and discrimination, then throughout all levels we need to change simplistic messaging, reduce blame and improve education and understanding of the complexity of obesity. The public deserve to receive accurate, evidence-based information. We wouldn’t accept inaccurate information about other health conditions. 

World Obesity Day 2018 - raising awareness, overcoming barriers

This year World Obesity Day, taking place on 11^thOctober 2018, focuses on weight stigma. By focusing on this important topic, World Obesity Federation (@WorldObesity) hopes to raise awareness about the presence and impact of weight stigma, and help people overcome the barriers that arise as a result of stigma which can prevent them getting the medical treatment they need. For more information about this year’s campaign visit www.obesityday.worldobesity.org. Here you will find resources including a latest report, infographics and a campaign toolkit for raising awareness about weight stigma in the media and helping to change the dialogue. 

About the Author

Dr Stuart W. Flint (@DrStuartFlint) is a Senior Research Fellow in Public Health and Obesity at Leeds Beckett University. His primary areas of research include weight stigma and discrimination, body image concerns, unhealthy food and drink marketing and physical activity interventions.