The Skin We Live In: Obesity stigma and the misdirection of responsibility

Obese and high-weight individuals are stigmatised and blamed for their poor health. This bullying approach is further harming these individuals and is not the solution to this complex health challenge

Alex Bogaardt

Last month in the US WW (formally Weight Watchers), launched Kurbo, a nutrition and weight loss app aimed at children aged 8 to 17. 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 life-long body dissatisfaction. As a psychologist working in a bariatric servicer, I would argue that this risk doesn’t end when the child grows into an adult. That weight-based stigma has negative mental health impacts and that the responsibility and blame placed on the individual for their poor health is both harmful and over simplified.   
​
Around a third of children in the UK aged 2 to 15 are already labeled as overweight or obese. Children are becoming obese at an earlier age, and staying obese for longer. Regardless of how we might 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, It is an approach to viewing weight that children are socialised to think is normal through culture, entertainment, advertising, health policy, as well as 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 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.

Cancer Research UK launched a campaign in July making a link between obesity and cancer with the word ‘obesity’ emblazoned across giant cigarette packets. By connecting obesity to smoking the campaign implied that individuals are responsible for their body size, like their smoking addiction, and therefore for any cancers they might develop. Despite people from lower income households having 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 and blaming individual behaviour rather than social systems. Despite research highlighting that the problem of obesity is driven by socioeconomic inequality, children face discrimination well before the age of 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% higher chance of being bullied. Teachers who harbour weight-based attitudes can also lower expectations of students, leading to lower educational outcomes for children and young people with obesity. Family members are often the main source of blame rather than a stable source of support. By the time these children reach adulthood their experience of this stigma may have already positioned them at a significant disadvantage. So, if as a society we are uncomfortable with an 8-year-old feeling that they are responsible for their weight at what point do we decide they are making a ‘choice’? 18? 20? 

Inequalities exacerbated

The fact is that weight-based stigma impacts us all, it is increasingly recognised as a mechanism by which social and health inequalities are created and exacerbated. 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 who are deemed to be at ‘healthy’ weights. Common responses to weight-based stigma include: social isolation, substance abuse, depression and anxiety, refusal to diet, increased food intake and avoidance of exercise. 

Weight-based stigma draws the line for who is acceptable and will be accepted into thin spaces at the same time as undermining individual ability to access them. This can lead to social isolation because of concerns of weight-based rejection. These anxieties threaten existing close relationships and discourage individuals from trying new activities or developing new social bonds. A 2013 US study found that people who were on the receiving end of weight-based discrimination during the previous 12 months, were twice as likely to be diagnosed with mood and anxiety disorder and were nearly 50% more likely to have a substance use disorder. People who have lost large amounts of weight often report they are surprised by how differently they are treated by others, having previously attributed negative interactions to defects in their personality rather than their size. 

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 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 against these individuals.
​
Additionally, adults with obesity report experiencing stigmatisation from health care professionals, which results in their avoidance of potentially lifesaving screening and increasing 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. The stigma experienced by people with obesity can lead to them not trusting the medical system to help with their poor health, further reinforcing the view that high-weight individuals are responsible for causing their health problems.  

Another way

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 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 levies on sugary drinks. However, although the need to address income inequality has been recognised by the government, progress on this front is at a standstill. No mention is made in the government’s strategy of acting to mitigate 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 people have experienced a difficult parental separation; others have witnessed or experienced trauma. Some have experienced 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, and by those closest to them, and as a consequence put on more weight. Some people 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; receiving note cards on public transport telling them they are fat, having drinks thrown at them while jogging or taking photographs of them in front of Cancer Research UK's ‘Obesity’ campaign posters and then sharing it 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 that do seek 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 what is needed. This would mean addressing weight-based bullying through integration with anti-bullying programmes and teacher training. 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, and placing restrictions on fast food outlets and 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% of their disposable income (after housing) on food to meet the UK Government’s Eatwell Guidelines. Addressing the cost of healthy food will need to be addressed alongside social inequalities. 

Public Health and healthcare professionals must universally recognise the damage simplistic obesity narratives can do, 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 which they live in. 

Author

Alex Bogaardt is a member of PSC London.