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Feeling discriminated against because of size can be traumatic. Here’s how to push back against the bias
Overcoming weight hate How to cope with society's bias
When Kelly Lenza, a professional photographer who has type 2 diabetes, hosts a party, she doesn’t just have to concern herself with the usual stuff such as what snacks to serve and how much wine to buy. She also has to worry about people commenting on, and openly judging, her larger-thanaverage body. At her most recent soiree, she was walking through the living room welcoming late arrivals when an older woman – an extended family member – tugged on her arm. “In the middle of the party, she pulled me aside to tell me that she thought my size was a choice and, to summarise, a moral failing. I went into the back room and wept,” Lenza recalls. “I emailed her later, telling her how hurt I was [and politely asked her not to comment on my body again]. But she hasn’t apologised, or even responded. I know she felt her comments were justified, because she thinks fatness is a choice.”
This partygoer’s hurtful behaviour is evidence not just of ignorance of the factors that influence one’s body size, but also of weight stigma: negative attitudes and behaviours towards a person because of their size, says Rebecca Puhl, deputy director at the Rudd Center for Food Policy and Obesity. Research by Puhl and her colleagues suggests Americans experience weight discrimination at rates comparable to those of racial discrimination, and that weight discrimination has increased in recent decades.
It’s so widespread, in fact, that at least 44 per cent of respondents from a US survey published in 2017 had experienced it.
Not only is weight discrimination humiliating, it is actively harmful to people’s health. A 2018 study of adults who had undergone bariatric (weight-loss) surgery reported the more weight-related stigma participants experienced, the more they avoided exercise.
And one long-term study of more than 18,000 middle-aged and older adults found those
who had experienced weight stigma were 60 per cent more likely to die early from any cause than those who did not. The increased risk wasn’t due to lifestyle choices or disease factors, leading the researchers to conclude the stigma may be more harmful than being overweight itself. This makes sense, given weight stigma has been linked with anxiety, depression, higher levels of the stress hormone cortisol and increased levels of C-reactive protein – an inflammatory chemical linked to heart disease.
Many people with diabetes already feel stigmatised because of their condition. “I heard one co-worker tell a child that if she ate too much cake she’d get diabetes. I’m like, that’s not how it works!” says Anastasia,
36, a youth-care counsellor who has type 2 and asked us not to include her last name. “A lot of the time, I don’t want to tell people that I have type 2. I feel like they will look at my body and think, ‘Oh, no wonder.’” Unfortunately, weight bias may be more harmful for those already dealing with other stigma and discrimination, as people with diabetes often are, says Puhl. “It’s important to recognise that people with diabetes are already at risk for a number of health complications – and weight stigma may make these worse.”
Myths about large bodies
“When we talk about weight bias, this includes widespread stereotypes like assuming that someone has a higher body weight because they are lacking discipline or haven’t ‘tried’ hard enough,” says Puhl. While dietary patterns and physical inactivity may contribute to weight gain, body size is also determined by many other complex factors, such as genetics, environment, socioeconomics and psychological factors such as trauma or disordered eating.
Researchers estimate between 40 and 70 per cent of obesity may be rooted in how our genes and our environment interact. Disordered eating and stress may also play a role, and both can be intensified by weight stigma. For example, a recent study found people who experienced weight stigma in adolescence were much more likely to engage in binge eating and to use food to cope with stress 15 years later when they were adults.
White-coat weight stigma
One of the most common places where people with high weight report facing bias is the doctor’s office. “One doctor said that ➤
he wished he could drop me in the middle of the jungle so I would have to hunt for my food and get exercise,” recalls Lisa Schieri, who was diagnosed with type 2 diabetes 27 years ago. Anastasia has felt stigmatised, too. “My regular doctor is great – he talks about diabetes management, not weight. But I had a painful cyst one time and had to see a nurse instead,” she recalls. “Out of the blue she says, ‘Have you ever thought about losing weight?’ ‘No, that’s never crossed my mind, lady. C’mon: I live in today’s world and have diabetes, what do you think?’ I cried in the car after.”
Such painful interactions can erode the doctor/patient relationship and lead people to avoid future medical care. Stigmatising experiences about weight may even contribute to additional weight gain, says Puhl. In a 2013 study of 6000 adults with a range of BMIs, those who experienced weight stigma were up to three times more likely to get or continue to have obesity over time than people who didn’t report any weight discrimination.
Physicians know it’s important to counsel patients about their weight, but most have little direct education in nutrition or behaviour change and are juggling too many patients to take the time to discuss real solutions.
“The generic advice from a doctor to ‘try again or try harder’ is not at all helpful,” says Dushay. “If something is not working, continuing on that path with more conviction won’t force it to work: if I don’t put the right fuel in my car, even if I overflow the tank with gallons of that fuel, the car won’t run. People may benefit from more nutrition education, more specific advice about shopping or planning meals, or more access to higher-quality food – all of which a good registered dietitian can provide – yet there is very frequently resistance to referring someone to a dietitian.”
Healing from weight stigma
Because weight stigma is so widespread – from healthcare professionals, the diet industry and family, to strangers – it can be difficult to overcome, and battling it is often a long-term process. In some cases, this battle can lead people of higher weight to internalise the weight bias, so there is literally no safe harbour, even at home, says
Puhl. Here’s how to fight back against weight bias in your life.
Check your own internal bias Find out just how many of these negative attitudes you’ve internalised by taking the
Weight Implicit Association
Test from Harvard University researchers. The test is part of their Project Implicit Social Attitudes research and can be accessed through Implicit.
(Visit implicit.harvard.edu/ implicit/australia/takeatest.html). Then, challenge your assumptions about size with
a book such as Body Kindness, by dietitian Rebecca Scritchfield, or Body Respect, by Dr Linda Bacon.
Evaluate your gaps
If your healthcare team isn’t providing you with the support you need, think about adding a member. Could you benefit from the support of a dietitian, health coach, personal trainer or psychologist?
Guidance from a dietitian has been shown to lead to greater improvements in HbA1c, and is strongly recommended by Diabetes Australia to help people with diabetes develop and follow an individualised nutrition plan. And, additional support from a psychologist can give you the tools you need to heal from internalised stigma. The Royal Australasian College of Physicians reported people who are obese or overweight must be supported by their health team in order to achieve the most optimal level of health.
Stand up for yourself
“When patients come to see me, I take it at face value that they are presently trying their best,” says Dushay. But not all providers have this attitude: a 2012 ➤
A lot of the time, I don’t want to tell people that I have type 2. I feel like they will look at my body and think, ‘Oh, no wonder.’
study of more than 2000 doctors found all of them held at least some negative opinions of large people, and all had an implicit – or subconscious – preference for thinner people over larger ones. Having strong negative attitudes towards weight could lead clinicians to think it is socially acceptable to express their negative attitudes towards people with high weight, even when those people are their patients.
If your doctor takes a condescending or shaming tone with you, speak up, says Juliet James, 43, a freelance writer with type 2. “It’s so hard to challenge doctors – we’re the patients, they’re the professionals.
They hold the education and experience cards. But they do not experience life in your body,” she says. “If you think something is ‘off’ or you feel you’re being mistreated, remember that and also remember: they are our employees! We don’t often think of them that way, but it’s true. They work for us. Why
Focusing on your quality diet and active life are the keys to success
on earth should we pay someone to treat us badly, to ignore our needs or wishes? We shouldn’t.”
Jill Weisenberger, dietitian and a contributing editor to US Diabetic Living magazine, agrees. “Each person who goes into a doctor’s or dietitian’s office has the right to say what they do and don’t want to focus on, or say, ‘I’m not comfortable with your suggestion.’ I know it’s hard, but don’t allow yourself to be in the situation where the provider is the boss,” she says. “These are supposed to be collaborative relationships.” If you’re not confident you can speak up, bring a friend or family member along for moral support.
Focus more on health-supportive behaviours, and less on the scale
All the experts we spoke to agreed that, while weight loss may be beneficial to someone with diabetes, healthy behaviours such as getting regular exercise and eating more nutritious foods are more crucial. “Learn to love high-quality food and recognise how great you feel when you eat it,” says Dushay. “People often feel better when they focus on the quality of their diet, eat more mindfully, and increase their exercise, especially vigorous activity. I encourage my patients to avoid focusing exclusively on the number on the scale.”