Understanding Obesity and Social Stigma

Female checking kilogrammes getting on the scale - self care and body positivity concept - warm flare on left

 

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It is well known that obesity is associated with a myriad of health consequences including type 2 diabetes, several forms of cancer, and obstructive sleep apnea. The prevalence of obesity is responsible for the prediction by health experts that, for the first time in history, the average life span of Americans could be trending downward.

What is less well understood and discussed are the social and psychological burdens of being obese. Studies suggest that this is another marginalized and stigmatized population.

Individuals with obesity are less likely to marry, typically earn less money, and even experience discrimination in the healthcare setting when compared to peers who weigh less. In developed countries, there is an inverse relationship between obesity and socioeconomic status. In other words, those who are obese are more likely to face socioeconomic barriers.

Obesity and Mental Health

Up to 60% of people classified as obese have a psychiatric illness such as depression. This is greater than the percentage of depression seen among the general population.

More specifically, those with obesity are more likely to meet the criteria for binge eating disorder, night eating syndrome, and emotional eating. Obesity also increases the likelihood of depression by five times compared to average-weight persons. Anxiety, particularly social anxiety, occurs in 9% of those seeking treatment for obesity.

These conditions tend to be significantly more common among women with obesity. This is likely due to the societal emphasis on thinness and physical appearance for women in many cultures. Women with obesity are more likely to endorse suicidal thoughts and attempt suicide compared to those of normal weight.

Weight-related discrimination, bullying, and microaggressions are associated with these adverse mental health outcomes. Individuals who report personal experience with bias and unfair treatment carry the greatest risk of depression, anxiety, and low self-esteem.

Furthermore, there is evidence that the chronic burden of living in a culture that rejects the overweight body type is associated with an increase in the stress and inflammation hormone known as cortisol. This is above and beyond the known metabolic effect of excess weight itself.

In other words, there is a known increase in inflammation associated with being obese. Then on top of that, the emotional burden of obesity increases inflammation and cortisol levels. 

Weight-Related Stigma

Ironically, there is evidence that as the prevalence of overweight and obesity rise, bias and prejudice against people with obesity also increases. Weight-related stigma in the U.S. is well-documented.

Weight-related campaigns that emphasize personal responsibility can also actually alienate their target audience. They may have the reverse psychological effect of increasing behaviors that contribute to obesity, such as binge eating and exercise avoidance.

Among Americans, weight discrimination is reported at rates similar to racial discrimination, particularly among women.

Several studies demonstrate that even children perceive people with excess body weight as lazy, unattractive, unintelligent, or lacking self-control. Some obese individuals may internalize these ideas and self-stigmatize. Absorbing this negative messaging from media or the social environment can have a detrimental effect on self-esteem and self-efficacy.

Furthermore, this can lead to additional weight gain and reduced weight loss over time. Although examination of this particular aspect of the effect of obesity prejudice is relatively new, it is generally accepted that weight bias adversely impacts health and psychological well-being.

The associated health risks that might be more prevalent among the obese may contribute to negative views towards this population. In turn, this can foster the idea that people who are obese are over-burdening the healthcare system.

Many obese individuals report experiencing derogatory comments and bias from family, peers, coworkers, and even strangers. Although weight discrimination is well documented, there are virtually no laws, public or institutional policies protecting the obese.

Obesity Stigma Among Children

Being overweight is the most common health issue facing children and adolescents. Often, the well-known consequences of excess weight do not arise until the adult years. However, the negative social and emotional fallout of obesity can be immediate and substantial.

Young people who are overweight often find themselves more marginalized and face higher rates of depression and low self-esteem than their peers. Overweight girls expect to be rejected by their peers and may even withdraw from social interactions as a way to cope.

Overweight Children Are Seen as Less Popular

Children as young as six years old describe obese individuals using negative and derogatory terms. In one study, a group of students (ranging from 7th through 12th grade) were asked to “nominate” friends based on preference. Results showed that overweight youth were found to be significantly less popular than their peers.

These findings were most evident among non-Hispanic, White women, which is a finding that holds true across multiple surveys looking at this issue.

Weight Bias in Healthcare

There are certain medical procedures that are not conducted in those with higher body mass index (BMI) such as fertility treatments or orthopedic procedures. Although this may be based on perceived risk or rate of success of a procedure in this population, it is known to contribute to health decline, worsening of disease, and avoiding the healthcare system altogether.

Many people who are obese report that, in the healthcare setting, any and all of their physical complaints are seen as a product of their weight. As a result, they do not feel taken seriously. Their experience is best described as a doctor not being able to see past their weight and attributing any and all of their presenting symptoms to their size.

COVID-19 and Weight Bias

Research suggests that individuals with obesity may experience greater COVID-related anxiety given the very public emphasis on the relationship between virus susceptibility and weight. However, it is also likely that the public discourse around weight during the pandemic era is also a contributing factor.

The changes during the global coronavirus pandemic led to unprecedented changes to daily routine, increased sedentary behavior and altered eating habits. Although there is some evidence that the average American gained weight during this period, the pervasiveness of this is likely overstated.

The majority of individuals, up to 59%, who lived in areas with a quarantine mandate reported maintaining their weight. A minority of less than 20% reported weight loss during this time.

In one survey, although 28% of participants reported weight gain during the pandemic, 65% of people reported increased anxiety about their weight and shape. There may also be recall bias regarding an individual’s pre-pandemic weight.

This became a prominent discussion in the news and social media, as topics like ‘Quarantine-15’ trended. Expressed apprehension and dread about weight gain may have fostered obesity discrimination.

Those who reported pre-pandemic experiences of poor treatment related to their weight were 2.4 times more likely than their peers to engage in binge eating and use eating as a coping mechanism during quarantine.

How to Reduce Obesity Stigma

Unfortunately, there have been very few successful stigma-reduction strategies proposed to date. It remains unclear which interventions would be effective in decreasing weight-related bias and the differential treatment of individuals with obesity.

Some have proposed that changes to public policy and legislation against workplace stigma, for example, would be helpful and that the people with obesity should be legally protected against discrimination.

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