The Harm of Weight Stigma

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I’ve written before about weight stigma in healthcare practice, and I’m currently co-authoring a study with Dr. Lesleigh Owen about the harm weight stigma does to the highest-weight patients. Today I’m going to dig into the research that already exists that explores the harm done to fat* patients by weight stigma.

As we get into the research, a few reminders:

First, weight stigma is rooted in and inextricable from racism and anti-Blackness, and continues to do disproportionate harm to those communities today. I urge you to read Sabrina Strings’ Fearing the Black Body – the Racial Origins of Fat Phobia and Da’Shaun Harrison’s Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness to understand more about this.

Second, typically research over-represents privileged people and under-represents (or fails to represent at all) marginalized people, and thus the harm done to them is also under- or un-represented.

Third, I wrote here about how weight stigma research is often still rooted in anti-fatness. I recommend reading this to contextualize a lot of the research and researchers I will talk about here.

Many of the studies that will be discussed in this article look at perceived weight bias/weight status. In this way, weight stigma can harm people of many different sizes, so just a reminder that weight stigma, in particular structural weight stigma, always does the most harm to those at the highest weights and/or those with multiple marginalized identities.

I also want to point out how often the things that are correlated with both weight stigma and body size are blamed on body size itself without any discussion of weight stigma as a strongly researched possible confounding variable (this is also common with weight cycling and healthcare inequalities.)

In this piece I’ll be looking at studies that show harm to physical and/or mental health, including iatrogenic harm, which means harm that is done by the healthcare system/healthcare practitioners. Weight stigma does much, much more harm in all aspects of the lives of higher-weight people that won’t be examined here. Also, this provides brief overviews of the studies included and is far from an exhaustive list. Please feel free to add other examples in the comments.

Finally, just a reminder that my policy is that when I refer to studies that perpetuate anti-fatness and harm, I will provide enough information to Google them, but I won’t link to them directly.

Last last thing before we dig in: studies refer to this variously as weight stigma, weight bias, sizeism, and other less common (sometimes more stigmatizing!) terms, I’m combining those for the purpose of this article.

Content note: This section will discuss physical and psychological harm that can result from weight stigma, including bias and self-harm, and may be harmful/triggering to higher-weight people, so please take care of yourself

I think therefore I am: Perceived ideal weight as a determinant of health, Muennig et al., 2008

This study looked at whether stress related to negative body image perception and the desire to lose weight could impact health, and found that the difference between actual and desired body weight was a stronger predictor of physical and mental health than actual body mass index (BMI) in cis women.

 “[cis] Women who say they feel they are too heavy suffer more mental and physical illness than women who say they feel fine about their size - no matter what they weigh.”

The body politic: the relationship between stigma and ob*sity-associated disease, Muenniug, 2008

This work examines the relationship between weight stigma and health issues, and finds that weight stigma may drive health issues that are typically blamed on body size.

“Stigma and prejudice are intensely stressful. Over time, such chronic stress can lead to high blood pressure and diabetes.”

The Weight of Stigma: Cortisol reactivity to manipulated weight stigma, Himmelstein et. al:

Young women who were told in an experiment that their weights “weren’t ideal” experienced higher levels of the stress hormone cortisol, regardless of their actual size.

“Experiencing weight stigma was stressful for participants who perceived themselves as heavy, regardless of their BMI. These results are important because stress and cortisol are linked to deleterious health outcomes...”

Associations between perceived weight discrimination and the prevalence of psychiatric disorders in the general population, Hatzenbuehler, 2009

• Perceived weight discrimination is associated with substantial psychiatric morbidity and comorbidity.

• The results remained significant after adjusting for perceived stress (a possible confounding variable)

• Social support did not buffer against the adverse effects of perceived weight discrimination on mental health.

• Controlling for BMI did not diminish the associations, indicating that perceived weight discrimination is potentially harmful to mental health regardless of weight.

They concluded that “These results highlight the urgent need for a multifaceted approach to address this important public health issue, including interventions to assist [higher-weight] individuals in coping with the mental health sequelae of perceived weight discrimination.”

Weight stigma as a risk factor for suicidality, Brochu, 2020

This study examined the connection between subjective perceptions of “overw*ight” and risks of suicidality and found that they were “associated with increased risk of suicidal ideation, plans, and attempt in a large sample of US adolescents, even when controlling for participant age, gender, race/ethnicity, body mass index (BMI), and depression.”

I think that this is part of the serious danger of the new AAP guidelines which call for an intense focus on the weight of children, starting to label them as “overw*ght” and “ob*se” as young as two years old.

Weight Discrimination and Risk of Mortality, Sutin et al, 2015

The study found that

• Perceived weight discrimination was associated with an increase in mortality risk of nearly 60%

• This increased risk was not accounted for by common physical and psychological risk factors

• In addition to its association with poor health outcomes, weight discrimination may shorten life expectancy

Weight stigma and health behaviors: evidence from the Eating in America Study, Lee et al., 2021

This study points out that “weight stigma is pervasive across the U.S. and is associated with poor health outcomes including all-cause mortality” and seeks to find if weight stigma drives poorer health behavior. (As a reminder, health is an amorphous concept and is not an obligation, barometer of worthiness, or entirely within our control.)

The study found that weight stigma was significantly associated with greater disordered eating, sleep disturbance, and alcohol use.

Overcoming Weight Bias in the Management of Patients With Diabetes and Ob*sity, Puhl, et al., 2016

The health impacts of weight stigma can include:

• increased blood pressure, blood sugar, and levels of the stress hormone cortisol

• reduced engagement with health care services, reduced trust of health care providers

• depression, anxiety, substance abuse, and suicidal tendency

• unhealthy eating behaviors, binge eating disorder, and lower motivation for exercise

• long-term health impacts including more advanced and poorly controlled chronic disease, and low health-related quality of life

I want to point out here, again, how much overlap there is with health issues that get blamed on body size, and that studies that link being higher-weight to health issues typically don’t even mention weight stigma, let alone control for it.

Weight Stigma Among Healthcare Practitioners that Can Impact Care

Stigma in Practice: Barriers to Health for Fat Women, Lee and Pausé, 2016
https://www.frontiersin.org/articles/10.3389/fpsyg.2016.02063/full

I recommend reading this in its entirety. Some of the highlights:

• Fat individuals are less likely to access healthcare, and are less likely to receive evidence-based and bias-free healthcare when they do engage

• Anti-fat attitudes are found in both practitioners and students, from physicians/doctors, researchers, clinicians, physiotherapists, dieticians, and nurses and  students in the medical and dietetic fields

• Negative attitudes about fat patients result in doctors choosing to spend less time with fat patients and often resulting in fewer preventive and diagnostic tests for fat patients

• Whether due to improper equipment, lack of education, bias, or an interaction between the three, it is clear that providers also present a barrier to the health and well-being of fat individuals.

Nurses' Weight Bias in Caring for Ob*se Patients, Tanneberger & Ciupitu-Plath, 2018

• Nurses found higher-weight patients lazy, stupid, noncompliant, less healthy, gluttonous

• Biases stemmed from belief that weight is under the individual’s control and/or that they would require more resources

Impact on Nurses

• Care was given out of disapproval or condemnation

Impact on Patients

• Canceling or delaying appointments after experiencing negative attitudes, discourteous treatment, and too small equipment being used during care

The Stigma of Ob*sity: A Review and Update, Puhl and Heuer, 2009

• Over 50% of doctors found their higher-weight patients awkward, ugly, weak-willed and unlikely to comply with treatment.

• 28% of nurses were “repulsed” by higher-weight patients

• 12% of nurses said that they did not want to touch higher-weight patients

Weight bias among health care professionals: A systematic review and meta- analysis, Lawrence et al., 2021

This is a systematic review and random- effects meta-analysis of 41 studies. It’s important to note the overall quality of these studies was very low and the authors point out the need for better-quality research.

“Findings show that medical doctors, nurses, dietitians, psychologists, physiotherapists, occupational therapists, speech pathologists, podiatrists, and exercise physiologists hold implicit and/or explicit weight-biased attitudes toward [higher-weight] patients.”

I agree with Lawrence et al that we need more and better-quality research. And I think a major aspect of better quality is research that comes from a perspective that affirms the existence of higher-weight people and not from a perspective that is fully invested in the pathologization and eradication of existing fat people and the prevention of any more from existing. Weight stigma research that is invested in the weight-centric paradigm, as so much of the research above is, both displays and perpetuates additional weight stigma.

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More research and resources:
https://haeshealthsheets.com/resources/

*Note on language: I use “fat” as a neutral descriptor as used by the fat activist community, I use “ob*se” and “overw*ight” to acknowledge that these are terms that were created to medicalize and pathologize fat bodies, with roots in racism and specifically anti-Blackness. Please read Sabrina Strings Fearing the Black Body – the Racial Origins of Fat Phobia and Da’Shaun Harrison Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness for more on this.