"The Impacts of Weight Bias in Healthcare"
Although total fasting can dramatically increase blood levels
of the stress hormone cortisol, as much as
doubling within five days, just dieting alone does not.
There is, however, a way stress and obesity could
turn into a vicious cycle: weight stigma.
Across thousands of individuals followed for four years,
those reporting discriminatory experiences
had more than twice the odds of becoming obese.
And those who started out obese had more than three times the odds
of staying that way compared to those who started out
at the same weight but didn’t experience discrimination.
Now, this could be from stress-induced eating
on one side of the calorie balance equation
or stigma-induced exercise avoidance on the other.
Obese individuals with more frequent experiences with
weight stigma report greater avoidance of exercising in public,
feeling judged and embarrassed.
These “too fat to exercise” fears may be well-grounded.
Strong anti-fat biases have been documented in both
fitness professionals and regular gym-goers, which may translate
into an unwelcoming environment in fitness centers and health clubs.
Whichever side of the calorie equation gets tipped,
those who experience weight stigma can also end up suffering
health consequences independent of any added weight.
Those reporting more frequent fat prejudice exhibit higher levels
of depression, higher levels of inflammation, and higher levels
of oxidative stress, as well as a shorter lifespan.
Two studies following a total of nearly 20,000 people
both found about a 50 percent increase in mortality risk
among those reporting greater daily discrimination.
Weight discrimination may shorten life expectancy.
Despite these hazards, some scholars advocate
for even more fat-shaming.
The President Emeritus of the prestigious Hastings Center
infamously advocated for “a kind of stigmatization lite,”
using social pressures to compel people to lose weight
without resorting to outright discrimination.
After all, he argued, what else has the potential to counter
the persuasive force of the billions spent in advertising
every year by the food and beverage industry.
It worked against tobacco.
He recalls his own battle with addiction:
“The force of being shamed and beat upon socially was as
persuasive for me to stop smoking as the threats to my health.”
The public health campaign to stigmatize cigarettes turned
“what had been considered simply a bad habit
into reprehensible behavior.”
When such campaigns have been tried, they have been met
with fierce resistance though.
Georgia’s Strong4Life campaign featured billboards of
morose-looking obese children with captions like
“Warning: Chubby kids may not outlive their parents” or
“It’s hard to be a little girl when you’re not.”
The campaign sponsors defended the ads as an attempt
to break through the denial in a state with some of the
highest recorded childhood obesity rates.
It’s only defensible, though, if it works.
Yale researchers found that when normal-weight women
provided with bowls of M&M’s, jelly beans, and chips
to snack on after watching clips of stigmatizing material
like clumsy, loud, lazy stereotypes getting teased
about their weight, they eat about the same amount
compared to watching neutral material such as insurance commercials.
But when overweight women watch the same two sets of videos,
they triple their calorie intakes
after watching the stigmatizing scenes.
The researchers concluded, “This directly challenges the notion
that pressure to lose weight in the form of weight stigma will have
a positive, motivating effect on overweight individuals.”
In other words, it could make things worse.
Being labeled “too fat” in childhood was associated with a
higher risk of becoming obese compared to children
weighing the same who were never told that.
But does that mean we should just ignore the elephant in the room?
Many doctors apparently think so.
Just as veterinarians have been found to be reluctant
to tell people their pets are obese,
fewer than a quarter of parents of overweight children report
having been told by pediatricians about their child’s weight status.
One might think it would be obvious,
but a Gallup Survey found that parents appear to be
“notoriously poor judges of their children’s weight.”
Similarly, the percentage of adults who describe themselves
as overweight has remained essentially unchanged
over the past few decades, despite skyrocketing obesity.
All this, Gallup concluded, helps “paint a picture of
mass delusion in the United States about its rising weight.”
I think patients have the right to be informed.
Those told by their doctor that they are overweight
have about four times the odds of attempting weight loss
and about twice the odds of succeeding.
Just as smoking physicians are less likely to challenge
their smoking patients, overweight physicians are less likely
to bring up the subject of weight loss
or even document obesity in their charts.
Ironically, overweight patients trust diet advice
from overweight doctors more than docs who are normal weight.
Unfortunately, primary care physicians appear
to have little to offer in terms of specifics.
Fewer than half who were surveyed said they provide
specific advice to their patients.
Just telling patients to “watch what they eat”
is unlikely to be particularly helpful,
but many primary care physicians may not even get that far.
Most physicians said they would spend more time working
with patients on weight management if only their time
was “reimbursed appropriately.”
Maybe we could offer a bonus to refrain from blaming the victim.
One pair of commentators wrote in response to the pro-stigma camp,
“If shaming reduced obesity, there would be no fat people.”
I want to end this weight stigma video series with the
jaw-dropping findings of a study that I think best illustrates
how hard it is to live inside a fat body.
If this doesn’t foster sympathy among my medical colleagues,
I don’t know what will.
Researchers talked to men and women who had lost and kept off
more than 100 pounds to tap into their unique insight,
having personally experienced what it was like to be
morbidly obese and then, on average, 126 pounds lighter.
Forty-seven such individuals were interviewed.
They were asked to think back to when they were heavier
and make a choice: “If someone offered you a couple of
million dollars if you stayed morbidly obese forever,
would you have chosen the money?
Or would you have chosen to be normal weight no matter what?”
Option #1 was, “I would have chosen no money and being normal weight.
It would have taken me about a second to decide.”
Option #2 was, “I probably would have chosen being normal weight.
But the possibility of having that much money
would make me think about the choice.”
Option #3 was, “I wanted to be normal weight,
but I really could use the money.
If I would be a multimillionaire,
I think I could live with being morbidly obese.”
One of the 47 had to think about it,
but the other 46 jumped at Option 1.
No one chose Option 3.
They all said they would give up being a multimillionaire
to be normal weight.
If that shocked you, buckle your seatbelts.
They were then asked about being obese compared to other disabilities.
Normally, when you ask people to choose between living with
their own disability or switching to a different one,
there is a strong proclivity to stay with their own.
For example, even though most people
would rather be deaf than blind,
blind people prefer to remain blind by a large margin,
rather than having sight without sound.
They already know how to cope with their own disability,
and so there’s safety in familiarity.
However, the exact opposite happened
when the formerly obese were asked.
Every single one of the 47 said they’d rather be deaf
for the rest of their lives than obese.
Every single one said they’d rather have difficulty reading,
be diabetic, have very bad acne, or heart disease than be obese.
More than 90 percent said they’d rather have a leg amputated,
and similarly, about 9 out of 10 said
they’d rather be blind their whole lives than obese.
Obesity appears to be the only handicap where nearly everyone
wants to switch, no matter what the cost.
To quote one study subject,
”When you’re blind, people want to help you.
No one wants to help when you’re fat.”