Every patient and family you see is inescapably impacted by weight stigma or fat shaming and the damage from this bias can lethal.

Published On: 09/19/22

Duration: 22 minutes, 54 seconds

Referenced Article: “Addressing Weight Stigma in Clinical Practice,” The Carlat Child Psychiatry Report, July 2022

Joshua Feder, MD, Mara Goverman, LCSW, and Sarah Nutter, PhD, have disclosed no relevant financial or other interests in any commercial companies pertaining to this educational activity

Dr. Feder: Every patient and family you see is inescapably impacted by weight stigma or fat shaming and the damage from this bias can be lethal. In this podcast, Mara and I will discuss this cultural conundrum, help you counterbalance the stigma, and help your patients to shield themselves from weight stigma with healthier attitudes.

Dr. Sarah Nutter joins us today to help us unpack this topic. She is an assistant professor in the Department of Educational Psychology and Leadership Studies at University of Victoria, BC, Canada. She is also a member of EveryBODY Matters, a multidisciplinary partnership of weight bias and obesity stigma researchers engaging in advocacy and outreach

Welcome to The Carlat Psychiatry Podcast.

This is a special episode from the child psychiatry team. 

I’m Dr. Josh Feder, The Editor-in-Chief of The Carlat Child Psychiatry Report and co-author of The Child Medication Fact Book for Psychiatric Practice. 

Mara: And I’m Mara Goverman, a Licensed Clinical Social Worker in Southern California with a private practice. 

Let's begin by talking about what exactly weight stigma is and how it is related to fat shaming. So weight stigma includes the stereotypes, negative attitudes/beliefs, and discrimination that all occur based on someone’s weight, typically when someone is perceived as too heavy. Internalized weight stigma occurs when someone directs these stereotypes, attitudes, and beliefs toward the self. Fat shaming is a form of weight stigma, where someone is made to feel badly about themselves due to their weight.

Dr. Feder: Fat shaming is also not isolated to one group. We live in a socio-cultural context that has really rigid body ideals. You know, thin and toned for women; lean and muscular for men and anybody who doesn’t conform to those body ideals is at risk of feeling shamed for having a body that doesn’t fit in.

Weight stigma is very much an issue that women experience, but men also experience weight stigma and are perhaps experiencing weight stigma on an increasing frequency, compared to the past.

Dr. Nutter, at what age do children become affected by weight stigma?

Dr. Nutter: Researchers have found that friendship preferences and social exclusion based on weight can occur in children as young as four and weight-based bullying is a serious concern for both children and adolescents. I would say it’s one of the common forms of peer victimization, according to some of the research that exists; and can sometimes be regarded as a safer alternative for attacking somebody than, say their gender identity of sexual identity.

And so, for children and adolescents who hold multiple stigmatized identities, attacking somebody for their weight can feel like the more socially acceptable target.

Mara: What are the consequences of weight based shaming and how does it affect development?

Dr. Nutter: I think the consequences of weight-based shaming and victimization can be especially pronounced for children and youth, given the pressure to conform and fit in with peers during these developmental stages. I think the body dissatisfaction and shame that can be felt by children and adolescents can contribute to disordered eating behaviors and potentially, that can lead to clinical eating disorders.

Anxiety and depression can also co-occur and all of these mental health challenges can carry forward into adulthood and influence a person’s mental health and relationship with their body.

I found one paper that was a longitudinal study of adolescents and risk of suicide and adolescents who perceived themselves to be overweight, it was found in the study have a 7.7% higher risk of suicide; and these researchers also found that the risk of suicide associated with perceiving oneself to be overweight has increased over time which I think matches the increase of perceived weight-based discrimination and weight stigma in society.

Dr. Feder: Society has created a message that weight is controllable through food and exercise behaviors, but in reality we know that weight is much more complex. Weight is contributed to by a highly interconnected set of over 100 causal factors, including biological factors, sociocultural factors, environmental, and psychological factors. 

Dr. Nutter: We also know from the research that weight isn’t a good proxy for health and that the relationship between weight and mortality is far more complex and nuanced than our cultural messages make us believe.  But that’s not what people receive on a daily basis, and people are so entrenched in this thinking that lower weights are healthy and so, when we think about these cultural messages trickling down into our everyday lives, it makes a lot of sense that people want to stay thin because the worst thing you can do is to be unhealthy and higher weight because people perceive that as a moral failing. And people who are struggling with their weight and can’t seem to meet the cultural expectation, well, of course, it’s really easy to feel like I’m going to give up and not engage in healthy behaviors because, why try at this point?

Dr. Feder: Can you talk more about the role that biological factors play in body weight?

Dr. Nutter: Yeah, absolutely. Genetics play – and other biological factors play a really important role in body weight. So, beyond our genetics we can think about pre-existing health conditions that are associated with weight. So, for example, endocrine disorders are associated with higher body weights. Medications that people take for health concerns can influence our body weight. We’re learning a lot in biological sciences about gut bacteria and how that can influence body weight.

So, there’s a lot there. But I also think it’s important to really look a little bit more broadly and to consider other social forces like our food environment and socio-economic status. You know, how does the food industry and the food that’s available to us based on what’s in our neighborhood and what we can afford, how does that influence health? How does that influence the weight that we have?

Do people have the capacity in their life to engage in health-promoting behaviors? Is there the physical space or the time in somebody’s life to be able to engage in physical activity? If we’re talking about somebody who has a lower socio-economic status and multiple part-time jobs to try to keep themselves afloat from month to month. You know, I think it’s also important to consider cultural factors and the influence that other forms of stigma can have on health and on body weight, as well.

Mara: I am interested in learning more about the impact weight stigma has on the health of people who are the targets of this stigma.

Dr. Nutter: We know that things like sedentary behavior are really important in predicting mortality and we also know that potentially some of the consequences – the health consequences that we attribute to obesity might actually be better explained by weight stigma. So, back in 2015, Angelina Sutin and colleagues published a paper on experiences with everyday weight discrimination and after controlling for a host of health-related factors and BMI, because weight and health aren’t the same thing, the researchers found that the experience of day-to-day weight discrimination was associated with an increased risk of mortality.

And so, I think – we live in such a weight-focused culture that perhaps some of what we put on weight as a health consequence might actually be attributed to the cultural stigma. But we haven’t necessarily teased that apart yet and a lot of people aren’t motivated to believe that weight stigma might be to blame more so than body weight itself.

Mara: I noticed you mentioned BMI. Since we typically track obesity using body mass index, what are your thoughts on it?

Dr. Nutter:  I have so many thoughts about BMI and none of them are positive! When we look at the history of the BMI and why it was created, to think of it as a potential population-level screening tool, sure. But we also need to think of what kinds of bodies BMI was created to be a population screening tool for and whether or not all kinds of bodies fall onto that spectrum.

But when we think about BMI as an individual-level health screening tool, I think it performs poorly and I do not think it should be used. A recent publication, I believe by Jeff Hunger and Janet Tomiyama and colleagues, looked at BMI and whether or not it did predict metabolic health of people across the weight spectrum and it did a horrible job! And other researchers have criticized BMI in the same way. It’s easy. You don’t need to draw blood and I think that it’s a convenient tool that people use, but it is in no way a good tool and we definitely need to move away from our use of BMI.

It’s also used to discriminate against people – insurance coverage and healthcare can be denied to people based on BMI.

Dr. Feder: As clinicians, we may inadvertently contribute to weight stigma by focusing on BMI numbers as well as other preconceived ideas about higher weights. How are providers redefining the way we approach body weight and overall health?

Dr. Nutter:  There is a shift away from BMI in the sense that health organizations are recognizing that weight isn’t a proxy for health, and we need to be able to infuse a little bit more nuance into the conversations and into healthcare.

So, for example, the new Canadian Clinical Practice Guidelines for the Treatment of Obesity in Adults has removed a focus on weight loss from their treatment recommendations and has made it very clear that obesity in Canada is defined as “adiposity that may impair health.” And the word “may” is really important because inherent in that is the recognition that not all people with higher body weights have obesity. Many people are perfectly healthy at higher body weights.

I think this redefinition is based on leading obesity science and that it’s important to emphasize that health is so much more than weight, than nutrition, than physical activity. By moving away from BMI, broadening our focus on health and focusing on health independent of weight, I think that there will be – hopefully – reductions in weight stigma that occur alongside that.

And I see a similar shift happening in other organizations, although places like the World Health Organization still definitely use a BMI-based definition of obesity.

Dr. Feder: Even if you are required to document BMI, frame your care in a way that avoids focusing on BMI. Instead, help your patient to cultivate positive attitudes about their body and engage in healthy living habits. Weight stigma and fat shaming can permeate care, including how you conceptualize your patient’s problem list, track their progress, and create treatment plans. Try to examine your own beliefs about weight and how those beliefs shape your attitudes and actions with patients. Lastly, support healthy attitudes and behaviors as opposed to focusing solely on weight.

Dr. Nutter, do you have some specific kinds of ways that we can talk to patients so that we’re not promoting fat shaming and rather promoting body positivity?

Dr. Nutter: Yeah, absolutely! I think the best thing that clinicians can do in conversations around weight or conversations around health is to dissolve the association between weight and health, so this might mean informing patients and their families about updated definitions of obesity, about the complexity of body weight, about the prevalence of weight stigma and its influence on health.

They think making the conversation around weight more complex can help people to understand that their weight isn’t their fault, and their weight doesn’t make them a bad person or a moral failing, and I think it can also help us to think about health a little bit more broadly, you know, when we remove that focus on weight from our own work or from our patients’ perspectives, you know, what kind of options do we open up?

You know, we know that 95% of people who lose weight through dieting and exercise will gain it back, often more, in three to five years. So, how can we focus on health independent on weight with our patients, rather than talking about dieting, let’s talk about intuitive eating and rather than talking about exercise for weight loss, let’s talk about building a joy of movement and finding activities that a person enjoys for the sake of the activity, not because of the perceived outcome of weight loss. And changing the conversations in subtle ways can improve our relationships with our bodies and also how people are feeling about their bodies. 

Mara: I like that you mentioned intuitive eating. For more clarification, intuitive eating uses mindful eating behaviors to help a person recognize their body’s hunger and satiety cues. This helps kids and teens pay attention to hunger, not deny it or deprive themselves. For example, if a teen is experiencing cravings for certain kinds of foods, you can say, “Eat when you are hungry. It’s OK to eat what you like.” Then consider the other reasons the patient is eating aside from hunger. Is it anxiety? Boredom? Is it medication related? Part of the family culture? Sometimes kids aren’t always self-aware that they are eating out of boredom, anxiety, or other related reasons. 

Dr. Feder: It is also important that providers work with patients to understand these reasons. Normally, with boredom, three emotions might be at play: feeling dissatisfied, feeling restless, or feeling unchallenged. Before thinking about solutions, ask the patient about these possibilities one by one. Differentiate with the patient or parents whether the eating is related to being physically hungry (eg, growling stomach, a headache, feeling shaky); craving a specific food, which may indicate a need for something in that food; being stressed, which often includes craving sweet, salty, or fatty food; or mindless eating, such as when a person munches on food while their attention is more focused on other activities like watching videos or sports.

But what should we do to help if we have confirmed that a kid is eating out of boredom?

Dr. Nutter: It’s important to recognize that if somebody is eating due to – boredom hunger that we don’t then shame an individual in response to that, that there’s all different kinds of ways that we cope with our experiences in our life. And so, to have I guess a value and judgment-free zone around that but to increase our awareness and understanding.

Mara: How should clinicians approach conversions with kids who have trouble exercising, maybe because they don't enjoy sports or aren't active?

Dr. Feder: Change the conversation. Rather than talking about exercise for weight loss, talk about building joy in the act of movement: “Let’s find activities that you enjoy for the sake of the activity, not to lose weight, and in places where you won’t feel judged or shamed.” Brainstorm ways to incorporate movements that make kids feel good in their day-to-day lives. This becomes something positive to track. On follow-up I’ll ask: “You’ve made some changes—do you have more energy? Are you sleeping better? Do you feel more in tune with or more capable in your body?”

Mara: How should we respond to patients who request weight loss medication or bariatric surgery?

Dr. Nutter:  I totally understand where folks like that are coming from. You know, living with weight stigma every day, especially for people who have more strongly internalized weight stigma. You know, their everyday experiences with weight stigma and discrimination are going to impact them far more than somebody who has rejected those cultural messages and more easy to, I guess, deflect those experiences when they happen.

And it makes a lot of sense to me that people would want to avoid weight gain at all costs or would want to do whatever it takes to lose weight. That’s a really natural and really unfortunate consequence of the culture that we live in. And so, I don’t want to judge people for making choices that they feel are serving them in that way.

If surgery is an option that’s being considered, I think it’s important to set expectations for what weight loss might look like. Lots of patients who get bariatric surgery are disappointed with their weight loss because they don’t make it down to the magic number in their head. Clients can also experience weight regain long term.

And there’s also just really drastic and lifelong changes that come with undergoing bariatric surgery. 

Dr. Feder: Also, look at the reason for the request. For a patient who will do whatever it takes to lose weight, the weight loss isn’t going to fix them. Is the request a reflection of internalized weight stigma? Educate your patients and create a plan that improves their health independent of weight. This includes intuitive eating, meaningful activities, and addressing social determinants of health. If you use medication, use it to promote health, not weight loss. 

Mara: Dr. Nutter, you briefly mentioned earlier how social forces like our food environment and socio-economic status can contribute to an individual's body weight. How do you address social determinants that impact health and weight?

Dr. Nutter: When I teach students (future counselors) about diversity considerations in counseling, we talk about every client, no matter their background, as being a client that warrants diversity considerations. Because people will hold all sorts of different identities. You know, we can think about racial and gender identity, sexual identity, but also socio-economic status and other kinds of things that will influence a person’s experience in the world and I think with anybody, especially knowing that weight stigma is a global concern, considering anybody’s economic, geographical, socio-political context is important and that the more we understand the broader social context of a patient’s life, the better we’ll be able to develop treatment plans that respond to the individual and their specific circumstances; and potentially that bring in considerations of other forms of stigmatization, as well.

So, I’m very much a proponent of individual lives and individual specific treatment plans, rather than something that’s much more cookie-cutter or manualized.

Mara: Overall, weight stigma impacts patients, and we are all culpable to a degree. Shift your practice from an emphasis on weight toward helping children and families develop positive and accepting attitudes about their bodies and healthier approaches to living.

Dr. Feder: The newsletter clinical update is available for subscribers to read in The Carlat Child Psychiatry Report. Hopefully, people will check it out. Subscribers get print issues in the mail and email notifications when new issues are available on the website. Subscriptions also come with full access to all the articles on the website and CME credits. 

Mara: And everything from Carlat Publishing is independently researched and produced. There’s no funding from the pharmaceutical industry. 

Dr. Feder: Yes, the newsletters and books we produce depend entirely on reader support. There are no ads and our authors don’t receive industry funding. That helps us to bring you unbiased information that you can trust. 

Mara: And don’t forget, you can now earn CME credits for listening to our podcasts. Just click the link in the description to access the CME post-test for this episode.

As always, thanks for listening and have a great day!

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The Carlat CME Institute is accredited by the ACCME to provide continuing medical education for physicians. Carlat CME Institute maintains responsibility for this program and its content. Carlat CME Institute designates this enduring material educational activity for a maximum of one quarter (.25) AMA PRA Category 1 Credits^TM. Physicians or psychologists should claim credit commensurate only with the extent of their participation in the activity.