Weight stigma and redefining healthy

Kendrin Sonneville: When public health professionals really center weight in conversations about health, this can serve to uphold or to justify messages of personal responsibility. It sends the message that weight and health are highly controllable and ultimately up to an individual to control. This focus ignores the complex ideology of weight and health and it can minimize social determinants of health, which is really the cornerstone of public health. It can also serve to justify the stigma that people in larger bodies face. It can serve to justify that stigma as an acceptable societal response to weight and to fatness. So this does not reflect the science, but if we are saying that weight is highly controllable on an individual level, it makes it easier to justify the type of mistreatment that people in larger bodies face.

Host: Hello and welcome to Population Healthy, a podcast from the University of Michigan School of Public Health. Join us as we dig into important health topics, stuff that affects the health of all of us at a population level, from the microscopic to the macroeconomic, the social to the environmental, from cities to neighborhoods, states to countries, and around the world. Kendrin Sonneville is an associate professor in the Department of Nutritional Sciences at the University of Michigan School of Public Health. Her research is focused on the prevention of eating disorders and utilizing weight inclusive nutrition and public health to improve the health of people across the weight spectrum. She wants more people to understand that health cannot come down to one simple metric.

KS: I started my career working as a registered dietitian before I even entered the field of public health, and I saw a lot of weight stigma in my clinical practice, even though I didn't have the language to describe it at the time. I was working in the eating disorder clinic, and the way that we treated people in thin bodies who had weight concerns is so different than the way that we would treat weight concerns in people in larger bodies. And it was that experience and that sort of cognitive dissonance that brought me to the field of public health. And I came to public health thinking I was gonna study eating disorders prevention because it is what I had worked with clinically. But the more I worked in the eating disorder prevention space, the more I saw weight stigma and anti fat attitudes to be really what was driving eating disorders on a population level. And the more I became passionate to recognize not just the role of weight stigma in eating disorders, but recognizing weight stigma more holistically and the impact it has in public health across lots of domains like the mental health domains.

Host: Weight stigma can have such meaningful implications, partially because many healthcare providers prioritize the number on the scale as a primary indicator of health. From Sonneville's view, this perspective is unreliable at best.

KS: The focus on weight as an indicator of health and public health has a complicated history, a long history. It's important to note that concerns about weight or fatness preceded any concerns about the relationship between weight and health. By the early 19th century, fatness was deemed evidence of immorality and of racial inferiority. So there is a racist history of body surveillance in this country, and it's useful to recognize that we didn't start talking about bodies and categorizing bodies for the sake of health, right? That we do have this history of utilizing surveillance in this way. So again, this was long before there was correlational data about the relationship between weight and health, and as concern about body weight or weight gain on a population level, as that increased, the public health and medical fields really shifted their focus away from tracking specifically height and weight to a focus on fatness. And this is when we see more widespread use of the BMI or the body mass index.

Host: BMI, or body mass index, is a ratio calculated using a person's weight and height. It's historically been used as an indicator of a person's weight status. In other words, BMI is used to determine if a person falls within the ranges that have been deemed obese, overweight, normal weight, and underweight.

KS: So we can use different indicators of health and increasingly we are seeing people use BMI categories as a proxy of health. We make an assumption that we can tell a lot about someone and their health based on their BMI. But there's research that tells us that when we use BMI as an indicator of health, we get it wrong quite a lot and depending on people's body size, we can get it wrong even half the time, which tells us the indicator is not working well at all. In one study, they found that when we use BMI as an indicator of cardiometabolic health, about 75 million Americans are misclassified. That is, we are making assumptions about their health based on their body size that is wrong. So there are a few ways in which I think public health has over prioritized weight as an indicator of health. One of those practices is BMI surveillance, where again, we are making assumptions about people's health or health behaviors based on their body size. The other one that comes to mind is our use of BMI as a study outcome, which is really common in public health studies and studies done in healthcare settings. When we use BMI as an outcome, we make assumptions about BMI or a change in BMI as being inherently good or bad.

KS: And this type of oversimplification can be really problematic. Again, the way that we often interpret BMI changes is that a BMI increase is bad and a BMI decrease is good, but there's a lot of variability in how individuals experience body size changes. So for example, if someone's weight is going up because they are engaging in fewer eating disorder behaviors or are no longer engaging in chronic dieting, this is good, right? This is a health behavior that we want, and again, the BMI increase is often interpreted as something that's negative. In the opposite direction, if someone's weight is going down because they are experiencing food insecurity or have experienced a trauma or other sort of mental health concern, this is not something to be celebrated. And we may use BMI as an outcome in studies because it's efficient, it's a single number, but it really distracts us from what we're trying to do in public health, which is to improve well-being and health in a way that is more holistically defined. There is an assumption in the general public that high weight is bad and that people in larger bodies who have health problems, it is their weight that is to blame. And what I want to offer is that there is a lot about living in a larger body that has nothing to do with body composition. We treat people in larger bodies poorly.

KS: They are facing weight discrimination in almost every domain in their life. They are getting lower quality health care because of the way that their bodies look. And there's lots of research that shows doctors are spending less time with patients in larger bodies and providing them less interventions. And so if we see worse health in people in larger bodies, we have to recognize that, that health or those health concerns may be due to the way that those bodies are treated and those people are treated and not because of the weight itself. And along the same lines, the solution to poor health is often not weight loss, right? The solution may relate to behaviors, to better access to health care, to less mistreatment. And we have to avoid making this knee jerk assumption that the best way to improve health for people is through weight loss. To date, there's actually been very little assessment of weight bias in public health campaigns or attention paid to weight bias in public health in general. What I have seen in public health is that we've been really focusing on interventions that are designed to change people's bodies, and that has been the focus of interventions to improve the health of people in larger bodies. And I'd really like to see the public health field invest in reducing anti fat bias as a strategy to improve the health of people in larger bodies.

Host: Weight stigma can take on many forms. It's not just about people's personal biases, it shows up in the structures that shape our everyday life. The term weight stigma itself is part of the growing vocabulary that has emerged in recent to identify the negative impacts of a weight focused culture.

KS: There's lots of terms we use to talk about mistreatment based on body size, weight bias or weight stigma, anti fat attitudes, fatphobia. And honestly, those terms, you will hear them used interchangeably. The way that I like to think about them is that weight bias is a term used describe the negative or stereotypical beliefs that people hold about people in larger bodies. And weight stigma really describes the way in which that weight bias is enacted. So this is where we see stigma that occurs on an individual level and structural levels. It's the enactment of our negative beliefs. Weight bias or weight stigma can occur on lots of levels. We think a lot about interpersonal weight stigma.

KS: And honestly, the field of weight stigma research has focused on really overt forms of weight stigma. That's weight related teasing or bullying or name calling. But weight stigma can be a lot more subtle or insidious. So relational weight stigma can look like not wanting to befriend someone who is in a body that is deemed unacceptable or undesirable in some ways. But it can also look like weight related comments, sort of assumptions about what people should or should not do or should or should not wear because of their body size. And in that way, it becomes a really daily experience for some people where they're always made to feel different or other because of their larger bodies. We also see weight stigma happen on a structural level. And some of the most harmful forms of this relates to where healthcare settings are designed with thin bodies as a default.

KS: We can think about the equipment in an exam room, the hospital gowns, the blood pressure cuffs. Equipment that is most readily available is equipment that is designed for thin bodies. We also think about weight stigma in healthcare settings being related to how services are withheld from people in larger bodies, most notably fertility treatment or joint replacement surgery or life saving gender affirming surgeries. There are many of these types of surgeries that folks in larger bodies are not able to access. Increasingly, we are using the term anti fatness or anti fat attitudes in the field to really name the people who are affected by weight stigma. People across the weight spectrum certainly can be mistreated because of their body size, but it is the people in large bodies and the folks in the largest bodies that are experiencing the most weight stigma or the most anti-fatness and are those that are most likely to be exposed to structural forms and really harmful forms of weight stigma.

Host: Sonneville's recent research explored the connection between weight stigma and mental health at a critical point in a person's development. As part of the Healthy Minds study, a web-based survey examining several mental and behavioral factors among the lives of college aged students, Sonneville's team sought to unpack the impact of weight stigma on the mental health of nearly 3,000 college students. Her research team found that about 12.3% of students experienced interpersonal weight stigma and 15.3% anticipated it. In other words, they expected to experience weight stigma at any given time. Whether experienced or anticipated the odds of developing mental health concerns were elevated for these students.

KS: In our study, weight stigma was consistently associated with poor mental health and this included increased symptoms of eating disorders, disordered weight control behaviors, binge eating and purging, also symptoms of anxiety and of depression. There wasn't much in this research that was totally surprising to me. We know that weight stigma is associated with worse health, worse physical health and worse mental health. What was surprising is a couple of things. One is that the relationship was as consistent as it was across many domains of mental health outcomes. I come from the eating disorder field and so we can often think about why weight bias might really relate to eating disorder behaviors. But in our study, we saw that experiences of weight stigma were associated not just with weight concerns and eating disorder behaviors, but also of symptoms and anxiety and depression. And it really speaks to how far reaching the impact of weight based discrimination can be. The other thing that was interesting about this study is that we asked about a type of weight stigma that is not so overt because most of the weight stigma research really focuses on weight based teasing and bullying, which we think of as maybe the tip of the iceberg and the types of stigma that people may experience. We wanted to understand about weight stigma and people's daily experiences.

KS: And so we asked them about how often in their daily lives people are acting as though they are better than them because of their body weight. So this felt like a sort of a low-level form of weight stigma, and even exposure to this type of weight stigma was consistently and strongly associated with negative health outcomes. What that tells me is that, again, the type of research that's focusing only on weight based teasing or bullying, that's just scratching the surface in terms of helping us understand how much anti fatness and weight bias is really harming the health of people.

Host: Sonneville explains why it's important to spotlight young adults when it comes to weight associated stigma.

KS: College students are at a vulnerable transition in their lives. From the period of adolescence through young adulthood, people are going through lots of changes in terms of how they think, but also in terms of how their bodies look. It's a time that's accompanied with kind of shifting identities, shifting locations, if folks are going away to college. And it's also a time where peer acceptance becomes really important, as does the social comparison of how am I fitting in with my peers. So it was not surprising to us that the extent to which people thought they were not fitting in or folks thought that they were better than them because of their body size, it's not surprising that that would be associated with how they feel about themselves related to symptoms of depression, anxiety, body satisfaction. And in our particular study, we saw that experiences of weight stigma led to more disordered eating behaviors. And this is something that we see young people, adolescents and young adults, but also older populations do to help themselves fit in. If they recognize they're being mistreated because of their body size, people can feel really desperate to engage in behaviors that are potentially really harmful in order to reduce their body size.

KS: The thing that's so frustrating about a finding like this is if you think about public health strategies that are focused on BMI surveillance, we do so much to tell people that their weight is high, right? I think about BMI report cards in public health settings or in clinical settings, it is really common for a doctor to comment on people's body size to let them know that their weight is over a certain cutoff. So we spend so much time telling people that their weight is "a problem" or is too high and when someone thinks their weight is a problem that is associated with more experience of stigma, more harm related to stigma, and we also know it's associated with worse health and worse health behaviors. So a finding like this reminds me that we have to really think about our public health approaches that are really designed to categorize people as having a weight that's over a particular cutoff.

Host: Through her work, Sonneville advocates for a shift in perspective. By adopting what's known as a weight inclusive framework and by centering the experiences of those directly affected by weight related stigma, she hopes that we can begin to move away from defining health solely based on weight and then recognize the harmful impact of weight bias on individuals well being.

KS: What a weight inclusive framework is is any approach that really emphasizes health and well-being as multifaceted. One thing I have taken to heart in my own work is to really think about the concept of research justice and sort of simply defined the concept of research justice as the idea that marginalized communities should benefit from the studies conducted about them. If you are someone who, like myself, is multi-privileged, you must really center the people whose lives you're trying to improve in the work that you do. It requires us to really critically reflect on our own privilege and power as researchers. And so I recommend that we are centering fat people in the work that we do. They are the ones who know best about their lives, their behaviors, and their experiences. We need to position fat people with diverse perspectives into active roles in weight related research. We need to pay them for their labor. So that is one thing I like to do is to recognize my limitations of my perspective and include more people who are directly affected by my research in my research process.

KS: I think also we should be following fat activists, creators, learn from people who are most harmed by anti fat oppression. You know, diet culture and anti fatness is so ubiquitous and normalized in our society. And if you are not someone who is deeply personally affected by it, it can be really easy to miss. And I think that is really the benefit of including more perspectives in your learning and in your research because it allows you to notice these things and to bring in perspectives that you can miss because you have not experienced it firsthand. I was trained in a way that made me think about weight as really central in how we define health and well being. Weight was the focal point for intervention and in utilizing weight inclusive frameworks, I'm trying to move away from this narrow definition.

KS: I want to be thinking about health, and health behaviors and their social determinants as the focal point for my intervention and to really recognize the way in which health access is differentially offered to people because of their body size and really think about how we can reduce weight stigma as a way again to improve health of people across the weight spectrum. There is a quote that I often use in a paper by Tracey Tylka that was one of the first papers to introduce weight inclusive frameworks to the broader scientific audience and she says that a weight inclusive approach challenges the belief that a particular BMI reflects a particular set of health practices, health status, or moral character and that's what I think about when I am studying weight inclusive framework is to avoid making assumptions about people based on their body size. We know nothing about them by just looking at the size of their body.

Host: Thanks for listening to this episode of Population Healthy from the University of Michigan School of Public Health. We're glad you decided to join us and hope you learned something that will help you improve your own health or make the world a healthier place. If you enjoyed the show please subscribe or follow this podcast on iTunes, Apple Podcasts, Google Play, Stitcher, Spotify, or wherever you listen to podcasts. Be sure to follow us at Umichsph on Twitter, Instagram, and Facebook so you can share your perspectives on the issues we discuss, learn more from Michigan public health experts, and share episodes of the podcast with your friends on social media. You're invited to subscribe to our weekly newsletter to get the latest research news and analysis from the University of Michigan School of Public Health. Visit publichealth.umich.edu/news/newsletter to sign up. You can also check out the show notes on our website, population-healthy.com, for more resources on the topics discussed in this episode. We hope you can join us for our next edition, where we'll dig in further to public health topics that affect all of us at a population level.