New England Psychologist
November 2017

Fashion magazines, television shows, movies and other media have promoted the idea that “thin is in” for decades. While there has been a slight shift in thinking recently, bias against larger individuals continues to be an issue that can have medical and psychological consequences.

According to Joan C. Chrisler, Ph.D., professor of psychology at Connecticut College, many clinicians don’t understand that a person’s weight is based on several factors, including genetics and physiology, as well as race, gender, age, income and culture, which collectively is known as intersectional identification.

Negative attitudes toward weight are also based somewhat on body mass index (BMI), a system the insurance companies created that suggests weight ranges, Chrisler noted, adding that this measurement was originally designed for research purposes.

“The terms ‘underweight’ and ‘overweight’ reinforce the idea of the perfect weight,” she said and noted that although BMI sounds scientific, it uses a random cutoff for obesity. “Obesity is a medical term and suggests there is something wrong. Lots of doctors think obesity is a diagnosis. It’s not. It’s a condition of the body, not a diagnostic process.”

Chrisler explained that explicit bias – verbalizing thoughts regarding weight – or implicit actions, such as subtle micro-aggressions, communicate negative attitudes.

“In a medical setting, the doctor might sometimes grunt or tsk when writing the person’s weight in the chart,” she said. “Several research studies and interviews reveal that women with excess weight experience micro-aggressions and prejudice every day. When you go to the doctor, you expect them to care about you.

[Patients] are seeking social support. If they don’t get it, it makes them feel bad. Experiencing mild shame or blame hurts.”

Often, clinicians assume a larger patient is seeking advice for losing pounds. “A therapist shouldn’t suggest weight loss unless the patient is asking about it. Making an assumption that losing weight makes life better is a common misperception,” Chrisler said. “Therapists need to learn about health at every size. There are lots of suggestions to give the patient to improve health and not to worry about the scale. Basically, this involves self-care.”

Chrisler suggested graduate school programs include “sizeism” as part of their diversity training. She said, “We’ve come further with gender identity and race. There should be training in sizeism, not only in graduate school for up and coming therapists, but also as part of continuing education.”

Weight-based bullying and teasing can have other consequences as well, according to Kathleen Hart, Ph.D., private practitioner in Falmouth, Maine, and president of Eating Disorders of Maine.

“Weight prejudice closes doors to jobs, relationships and even treatment,” she said, noting that media has been a major contributing factor in promoting a narrow body ideal that devalues and discourages body diversity and body acceptance.

“By the1950s, media discovered the power of changing the cultural standard for female bodies to a thin ‘Twiggy’ body ideal. Because this beauty ideal is unattainable for 98 percent of women, it has served as a powerful tool to sell products to women trying to attain an unrealistic body type. Even the newest trend of promoting the ‘curvy’ body limits diversity.”

“As health care providers, we need to be sensitive to weight diversity and avoid weight- centric medical practices. Weight does not predict health. Movement is a better predictor of health than weight,” said Hart.

“To ask your patient to jump on a scale every time they seek medical care is only sending a message that weight matters. Clients often tell me that they avoid going to their doctors because they don’t want to get weighed and therefore delay seeking medical treatment for physical complaints until the symptoms worsen and they have to seek treatment.”

Hart believes in the empowerment model of changing behaviors, which involves placing some decisions in the patient’s hands. “As a healthcare provider, providing positive feedback about how your patients are taking care of themselves empowers them to continue engaging in behaviors that promote health,” she said.

“If your patient needs or wants to change their eating behaviors, instead of recommending dieting, ask them to add something to their diet, such as two fruits a day, and then come back in two weeks to see how it went.”

Hart said, “Fat shaming and weight-bullying is not only cruel and hurtful, but it also can trigger low self-esteem and the development of eating disorders.”

The National Eating Disorders Association reports that as many as 65 percent of people with eating disorders say bullying contributed to their condition.

“Like any other form of bullying and discrimination based on race, religion, gender or weight, this can lead to feeling bad and shameful about oneself and create a sense of not belonging,” she said. “Brené Brown describes shame as ‘the fear that we’re not good enough’ and that we don’t belong. When we don’t feel as if we belong, this can lead to depression and suicidal thoughts.”

In some cases, practitioners might use shaming as a motivational tool. Kate Craigen, Ph.D., clinical director, binge eating and bariatric support services at Walden Behavioral Care, said, “Unfortunately, what we know is that shame is not a catalyst for change. It doesn’t make you stronger. Weight is a complex issue that involves biological and environmental factors.”

Craigen reported that, in some cases, implicit shaming might reflect the healthcare provider’s attitudes. “Practitioners may make assumptions about personality and lifestyle of people in larger bodies. These assumptions drive interventions,” she said.

“Medical professionals repeatedly have conversations about weight loss as the main problem. They think it’s an issue over which the patient can and should get control. It implies that if a person could just change or make changes to her shape, other things in life will change.”

However, research shows individuals who feel stigmatized engage in more caloric intake of food, such as emotional or binge eating and they may exercise less, according to Craigen. “There are mood-related consequences, such as anxiety about being in public spaces. Repeated incidents can cause weight stigma internalization.”

“We need to raise awareness of our own implicit biases to interrupt the pattern of assumption. An important first step is to have understanding when making decisions based on a person’s character as it relates to weight,” said Craigen. “There is no right or wrong body size. It’s important not to make the assumption the weight is a primary issue for the person.”