Global health policy Opinion - 11/October/2021

Obesity and Mental Health: Addressing Stigma and Misconceptions

Obesity is one of the most urgent global health challenges of the 21st century. Prevalence rates have reached pandemic proportions, global obesity targets are catastrophically off-track, and health systems across the globe are almost uniformly ill-equipped to address care and prevention. As obesity rates have increased so too has weight stigma - the negative behaviours and attitudes that are directed towards individuals solely because of their weight. Addressing weight stigma is vital to successfully reversing the impact of obesity.

The views expressed are those of the author and do not necessarily reflect the position of FORESIGHT Global Health.


 

Weight stigma adversely affects millions of people living with obesity every day and can lead to serious mental health issues, including depression. A recent systematic review on the connection between weight stigma and the physical and psychological health of people living with overweight or obesity, as well as data from the World Obesity Federation, highlight an association between the two. Potential adverse outcomes may include higher levels of obesity, eating disturbances, anxiety, depression, lower levels of self-esteem and body dissatisfaction.

Stigma and weight bias results from misconceptions about the root causes of obesity, which is in many cases driven by forces outside of a person’s control. Drivers include biology, genes, mental health, access to healthcare and exposure to ultra-processed foods, as well as factors outside of the health sector and associated with economic, environmental, commercial and social determinants. We know for instance that 40% to 70% of obesity is linked to genetics. The environments in which we live and work and play compound this risk by limiting access to physical activity, promoting intake of cheap, high energy density food, and encouraging deviation from optimal sleep quality and duration.

 

MEDIA, HEALTH PROVIDERS HELP SPREAD NEGATIVE MESSAGE

Despite this, we commonly see a strong blame narrative in many countries, especially in Europe and the Americas. People with obesity are often mischaracterised as “lazy” and other negative labels that can inhibit  comprehensive prevention and management measures and instead propagate weight stigma. The media is a key perpetrator of stigma, and all too often represent people living with obesity with negative words and images, usually eating junk food and engaging in sedentary behaviours. “Fat”, “chubster” and other denigrating terms  are all adjectives that are used in popular global news outlets. There is a significant disconnect between what we know about the causes of obesity, and the way people living with obesity are being written about and depicted by the media.  The harmful media narrative has been shown to lead to undesirable stereotypes attributed to them are true and that they deserve the negative responses they receive.

Unfortunately, health care professionals – due in part to lack of training in obesity as part of their professional studies – are also amongst the primary perpetrators of weight stigma, with people living with obesity reporting receiving lower quality care from providers, or even avoiding seeking care. In a recent survey completed by 2,380 primary care patients with a BMI higher than 25 kg/m2, 27.5% of respondents reported delaying needed care and 13.7% reported delaying seeing a doctor due to prior experience with weight bias. These challenges in accessing even the most basic of care can contribute to poor mental health such as depression amongst people living with obesity.

At the same time, misconceptions about weight and obesity are not homogenous globally, and cultural perceptions of weight vary widely.  Among populations in many African countries,  for instance, overweight and obesity are commonly viewed favourably and seen as a sign of good health, signaling prosperity or the absence of certain communicable diseases such as HIV. In countries such as Mauritania, Uganda and Sudan, Leblouh – a common force-feeding practice in a culture where obesity was traditionally regarded as desirable – remains acceptable and girls aged 5-19 years are sent to camps and force-fed a diet of up to 16,000 calories a day in preparation for marriage. Regardless of how it manifests, the lack of understanding about the causes and complications of obesity is universal and is a critical factor in the continued increase in obesity worldwide, as well as its association with poor mental as well as physical health.

 

REFRAMING PERCEPTIONS OF OBESITY

So what can be done? Raising awareness about the effects of stigma and addressing common misconceptions about obesity are important steps in helping to reduce it and the mental health complications that are associated with it. This requires us to challenge the underlying blame narrative and perception that obesity is a simple condition which can be solved by eating less and moving more. Changing the language and imagery around weight can transform public perceptions about obesity, improve quality of life and outcomes for people living with obesity and in turn help address weight stigma and mental health complications.

Though not an easy task, everyone in society has a role to play by putting aside their biases and recognising the complexities of this multifactorial disease and driver of other diseases. The media plays an instrumental role in shifting this bias, particularly by improving the language used to described obesity and ensuring that respectful imagery is used. Doing so can allow media outlets to reframe obesity by telling a more accurate and human-centred story which can in turn change perceptions, improve understanding and reduce weight stigma. Using people-first language, acknowledging that obesity is complex, and shifting the focus of solutions to the need for comprehensive policies —which improve healthcare services, as well as food and physical activity environments—can go a long way.

Greater sensitivity and efficacy from health care providers is needed to diagnose, support and treat people living with obesity in a patient-centred and compassionate way. Primary care professionals have the advantage of being able to follow individuals through the life course and have multiple opportunities to provide the care and support that people with obesity need. To support health care professionals requires more evidence-based guidelines and training to equip them with the proper tools to approach the topic in a sensible, culturally appropriate and non-stigmatising manner.

As evidence accumulates about the degree to which obesity is a disease beyond the agency or control of the induvial, it is quite shocking that stigma, blame and negative imagery are so prevalent.  Indeed, weight stigma represents one of the last socially acceptable forms of discrimination and as Dr. Abd Tahrani notes, “If blame worked, we would have a very thin society by now.”  Years from now, it is likely that people will look back on the maltreatment of people with obesity, even by the media and health systems, and regard it with the same dismay and regret that episodes of, say, medical racism are now viewed.  Two of the primary disseminators of stigma – healthcare professionals and the media –  can not only play a role in reducing weight bias and its attendant mental health impacts but can become leaders in tackling  weight bias head on to shift the wider narrative and public understanding of obesity. People with obesity deserve this, the prevalence and risk of obesity demand this, and we all have a role to play. •

 

TEXT – Dr. Fatima Cody Stanford practices and teaches at Massachusetts General Hospital/ Harvard Medical School as one of the first fellowship-trained obesity medicine physician in the world. She is an expert in obesity medicine, who bridges the intersection of medicine, public health, policy, and disparities and has received numerous awards to reflect her expertise including the Gold Congressional Award, the HMS Amos Diversity Award and Massachusetts Medical Society Award for Women’s Health, amongst others.

Lesly Samara Vejar Renteria is a researcher at the National Institute of Public Health in Mexico where her focus is on health policy development, advocacy, and, monitoring and evaluation. She was formerly a policy officer at the World Obesity Federation working on topics related to health-policy including front-of-pack food labelling and city level interventions.

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