Stigma adds fuel to the obesity epidemic

IN THE 2009 FILM PRECIOUS, the main character, Claireece “Precious” Jones, a Black teenager with obesity who lives with her abusive mother in New York’s Harlem neighborhood, starts her day by primping in front of a mirror. Instead of seeing a reflection of herself, though, she envisions a thin, blonde white girl—society’s stereotypical ideal of teen beauty. Hungry, Claireece asks her mother for money to buy food but gets turned down. So she goes to a nearby diner, orders a 10-piece bucket of fried chicken, flees without paying, devours the chicken as she runs through city streets, and vomits into a wastebasket after she arrives at her social worker’s office.

This episode dramatically illustrates the harm that social stigma does to people with overweight conditions. Obesity experts at Yale School of Medicine say that until society and the medical profession figure out how to deal effectively with weight bias and stigma, it will be difficult to halt the growth of the obesity epidemic. “Stigma is pervasive and creates a vicious cycle,” says Janet Lydecker, PhD, assistant professor of psychiatry. “It leads to stress, which leads to binge eating, to weight gain, to poor treatment from others, and to more stigma. It just keeps growing.”

In addition, obesity and weight stigma are often associated with mental health issues—not just eating disorders such as binge eating and bulimia nervosa, but also anxiety and depression. According to one study, over half of the people who experienced weight stigma also had at least one psychiatric disorder.

At the core of weight stigma is the widely held yet false belief that people with overweight conditions have only themselves to blame: They are heavy because they lack the self-control to avoid becoming overweight and the willpower to lose weight. Some people with overweight conditions also blame themselves—a phenomenon called weight-bias internalization, which further diminishes their self-esteem and often leads to overeating.

Obesity is a frequently stigmatized chronic medical condition in part because the problem is immediately visible—which makes people who suffer from it particularly vulnerable to discrimination and derisive comments.

Eradicating words that hurt

When it comes to body weight, there’s tremendous variety and savagery in the language of disparagement; many hurtful words likely come to mind. To make matters even worse, there’s a strong impulse in society, even among well-meaning people, to pressure those with overweight conditions to do something about it—“tough love” that often involves harsh accusations. Even some physicians use language that further traumatizes the people they are trying to help.

That’s why a movement is afoot to destigmatize the language we use when talking about body weight. A group of Yale researchers in 2016 conducted a survey of people with weight issues aimed at identifying harmful words and phrases as well as preferred terms. Harmful language included “excess fat,” “large size,” and “obesity”—which is the official medical term to describe the condition of being severely overweight. Preferred terms included “BMI” and “unhealthy body weight.”

In their journal article, published in the International Journal of Clinical Practice, the authors urged health care professionals to avoid using stigmatizing language when talking to patients. The same guidance applies to everybody in society. “I think the safest thing is to not use ‘obese’ as an adjective. Say ‘people with obesity’ rather than ‘obese people,’” advises Carlos Grilo, PhD, professor of psychiatry and of psychology.

The power of language should not be underestimated. The National Eating Disorders Association argues that the rise of national obesity prevention campaigns in the United States has actually contributed to the incidence of weight stigma, in part because of the language that weight-loss advocates use. The messaging from marketers of weight-loss products and services is also hurting rather than helping. Journalists are prone to using inconsiderate language, as well.

Weight experts had hoped that when the American Academy of Pediatrics published its first-ever clinical practice guidelines for evaluation and treatment of children and adolescents with obesity last January, it would help destigmatize the condition. Unfortunately, some parents reacted strongly against a new recommendation that pediatricians consider prescribing medications for adolescents 12 years and older. “People said, ‘How can we put our children on medication?’” says Mary Savoye, RD, associate director, Yale Pediatric Obesity. “But if a child has asthma, they are prescribed an inhaler. Why is obesity treated differently? It’s because of stigma. It’s supposedly the person’s fault.”

Until recently, there were no truly effective medications for the treatment of obesity. Now, physicians can prescribe semaglutide (brand name Wegovy®) and liraglutide (brand name Saxenda®), which are FDA-approved for weight management in people with obesity or overweight. In addition, diabetes drugs, including Ozempic® (the brand name of semaglutide when it’s prescribed for diabetes) and tirzepatide (brand name Mounjaro®), promote weight loss. The medications approved for chronic weight management should be combined with nutritional and physical activity counseling, and, ideally, with lifestyle behavioral counseling.

Adopting a new calculus

For Yale School of Medicine programs that combine clinical care with research, destigmatizing weight is part of the calculus that goes into the treatments and language that appears in medical journal articles and in conversations with patients and families.

Grilo directs the Program for Obesity, Weight and Eating Research (POWER) at Yale. Since he launched the program in the mid-1990s, it has focused on developing and testing approaches for helping people manage diverse eating and weight concerns, including eating disorders and obesity. Treatment decisions are highly personalized and target specific behavioral and psychological needs, including body-image concerns. “We view our patients and participants in our treatment studies as ‘collaborators’ in both the treatment process and in the research goals of helping advance knowledge to help others,” says Grilo.

Faculty members in the program were among those laying the groundwork for the medical profession establishing binge-eating disorder (BED) as an officially recognized formal diagnosis in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) classification published in 2013.

One of the complexities that physicians who treat obesity face is the fact that most popular diets do not work long term for most people, which amplifies feelings of inadequacy and failure. The typical pattern is for people with excess weight to lose weight in the initial stages of a formal diet but then regain it over the long term. That’s why Grilo and other Yale specialists work with patients to develop sustainable lifestyle eating plans involving healthier nutritional and eating behaviors, increasing physical activity, improving coping skills, and enhancing body image. Importantly, these effective approaches help patients stay away from restrictive and unhealthy weight control attempts.

For Grilo, addressing stigma is an essential piece of what he sees as a winning prescription for dealing with obesity on a national scale. His three key calls to action are strengthening regulations governing unhealthy foods (calorically dense, high-salt, overly processed foods with limited nutritional value); promoting compassion and respect; and switching the focus from dieting to achieving healthy lifestyles.

Protecting children and teens

Obesity is an even more confounding problem when it comes to dealing with children and teens. That’s partly because there is so much intense bullying in the early years. Family and physician pressures also play a powerful role. Yet it is critically important to identify these issues before individuals establish cognitive and behavioral patterns that could stick with them for life.

Bullying has tremendously negative consequences, including self-harm and suicide, yet little research has been done on the impact of bullying on children and teens with obesity and eating disorders, according to Lydecker, who runs the teen program at POWER at Yale. One result is that few teens get treatment for weight bullying. That’s why she and her colleagues launched a study and developed a new treatment approach, which includes weekly talk-therapy sessions focused on helping the young people process the trauma of being bullied.

“Cyberbullying is the worst,” says Lydecker. “It retraumatizes a child every time somebody comments or shares a post. They feel they’re being targeted by the whole world, and it doesn’t stop. Sometimes, bullies even urge kids to kill themselves. It’s horrible and unthinkable, but it’s happening.”

In their work with teens, Lydecker and her colleagues embrace a “body-neutrality” approach. They urge teens to focus less on their appearance and more on taking care of their bodies so they can do what they enjoy in life. She also publishes social media posts on Instagram and Facebook to share practical information about eating disorders and to spread positive body-neutrality messages.

Lydecker’s most recently published research focuses on school problems caused by weight bullying. Through interviews with parents, she and colleagues found, for instance, that children who had experienced verbal weight bullying were more than two and a half times as likely to skip school as those who were not verbally bullied. They wrote that the research provides further evidence that weight bullying is detrimental to children’s well-being, and they called on schools, communities, and clinicians to take it seriously and develop strategies to reduce it.

Body neutrality for children, teens

At Yale’s Bright Bodies Healthy Lifestyle Program for children and their parents, the staff and volunteers are so focused on avoiding stigma that they don’t require kids to stand on a scale at first. They don’t even call it a weight-reduction program. Mary Savoye, the dietitian who launched the program more than 25 years ago, advocates a “non-diet” approach. She and her colleagues talk through real-world situations with the kids and help them understand how to respond to urges, to avoid unhealthy foods, or to just eat less of them. “Diets don’t work. We empower the children to make the best choices they can in any given situation—which helps build self-esteem. We do a lot with nutrition and exercise, but we’re also heavy on behavior modification,” she says.

The staff at Bright Bodies also factors stigma into the way they measure progress for their young patients. In addition to monitoring changes in BMI and body fat, they also use surveys that trace the impact of the program on a child’s self-concept and quality of life.

The Bright Bodies program has been adopted elsewhere in the United States and around the world. Unfortunately, lifestyle programs like it are not supported by most health insurance policies. As a result, they’re hard to launch and sustain. Savoye raises money for her program through grants and charitable contributions, and she recruits students and medical professionals to help on a volunteer basis.

Savoye and Mona Sharifi, MD, MPH, associate professor of pediatrics, received a $3.96 million grant from the National Institutes of Health (NIH) to study the implementation of Bright Bodies nationally, and the Centers for Disease Control and Prevention has recently funded applicants in all 50 states to implement family healthy-weight programs like it.

Protecting populations most at risk

While obesity affects people of all races and ethnicities, it is more prevalent among people of color. For instance, 49.6% of non-Hispanic Black adults and 44.8% of Hispanic adults have obesity compared to 42.2% in non-Hispanic white adults, according to the NIH. Although these variations have many causes, researchers point to differences in social and economic status related to race or ethnicity.

In poor neighborhoods, people have limited access to nutritious food. Social and economic stresses can drive binge eating. Certain regional and cultural traditions also can promote unhealthy eating—think heavy pasta or rice dishes, fried chicken, and sweet tea. Another factor: food producers aggressively market unhealthy foods and beverages to poor people.

When you combine the factors of weight, poverty, and race, people in racially segregated communities face a triple-whammy of stigma. “Environments make it hard to have a healthy lifestyle and healthy weight,” says Sharifi, whose research focuses on obesity prevention and treatment in community settings as well as psychosocial factors in the emergence of childhood obesity in communities affected by health inequities.

Sharifi calls for more screening for weight issues earlier in life and earlier interventions—especially for children in disadvantaged neighborhoods. But she cautions that health care providers must be thoughtful about how they ask about food and weight gain—to avoid further trauma and stigma.

Sharifi says she is alarmed by the obesity epidemic, but, as one of the authors of the new pediatric obesity guidelines, she is also optimistic that we can make progress against it. The guidelines promote non-stigmatizing and family-centered care, and new and effective treatment options, including medication. They also acknowledge the role of social issues, psychosocial factors, the environment, and genetics, which all collide to cause obesity.

“If we as a nation are going to address this, we have to do it at the health care level for those affected, and at the societal and policy level for prevention,” she says.

For Gabourey Sidibe, the actress who played Precious in the movie, life since then has been a mixed bag—success as an actress, but continuing struggles with weight and stigma. She is open about her experiences with bulimia and depression. She has type 2 diabetes and underwent bariatric surgery to control her weight. She regularly sees a nutritionist and a therapist. “Being depressed is one thing. If you add an eating disorder to that, that’s a whole other monster you have to fight,” she said on Taraji P. Henson’s Facebook Watch talk show, “Peace of Mind with Taraji.”

Savoye of Yale seemingly speaks for Sidibe and all people who struggle with weight when she says: “A healthy lifestyle is a journey. Things don’t happen overnight.”