As mental health professionals we are trained in cultural competence and diversity. We often attend trainings about vulnerable populations and how to best serve them. Furthermore, we are trained to look at our own biases so that we do no harm to our patients. Unfortunately, we don’t get much training or any at all, about treating patients in larger bodies, despite good evidence that weight stigma is present in our society.
What is Weight-Bias & Stigma?
Assumptions about competence, health status, intelligence and productivity are all examples of common and inaccurate stereotypes of people living in larger bodies.
Bias, according to dictionary.com, means “a particular tendency, trend, inclination, feeling or opinion especially that is a preconceived.” Stigma, as described by Miriam-Webster on-line dictionary, “is a set of negative and often unfair beliefs that a society or group of people have about something.”
People who live in larger bodies (often referred to as obese or overweight), experience bias and stigma because of their body size. The labels “obesity” and “overweight” can be stigmatizing in of itself as it assumes that there is only one “right size” for a body to be. Like other biases and stigmas, weight-bias and stigma occur across many areas of life including education, occupation, health and mental health settings.
What Does Weight-Bias & Stigma Look Like?
In schools, weight-based victimization, includes children and teens being signaled out because of their weight, usually in the form of verbal teasing and/or exclusion–and in some extreme cases, physical harm. Studies have show that 64% of children who live in larger bodies experience weight-based victimization at school. According to the UConn Rudd Center for Food Policy & Obesity, adolescents report that weight-based teasing is more common than other types including teasing about race, religion and disability. Weight-based teasing has similar rates of teasing based on perceived sexual orientation.
In the workplace, examples of weight-bias and stigma include being passed up for promotions and job offers, targeted by co-workers with weight-based jokes and penalized by company benefit programs for not losing weight. A 2007 study showed that people living in larger bodies were at least 37 times more likely to report weight-based discrimination at work compared to their “normal” weight co-workers.
In healthcare settings, weight-bias includes providers spending less time in discussion with patients, reluctance to perform preventative screenings and refusal to provide certain medical services.
According to a policy brief by the UConn Rudd Center for Food Policy & Obesity, 52% of women living in larger bodies reported that they had experienced weight-bias from their doctors It has been my clinical experience, that many people living in larger bodies avoid going to the doctor all together as they are fearful of being harangued by the doctor about their body weight.
In a study completed in 2000, it was shown that psychologists ascribed more pathology, severeymptoms and worse prognosis to patients living in larger bodies compared to “normal” weight patients. Furthermore, eating disorder treatment providers have been shown to have weight-bias and stigma similar to other healthcare providers.
Harmful Effects of Weight Stigma & Bias
Contrary to popular belief, body weight is not as changeable as the diet industry leads us to believe. In fact, only about 5-10% of people who lose weight can keep lost weight off for a significant amount of time. Therefore, dieting, the intervention, is flawed, not the people who diet.
Many well-intended parents, spouses, teachers and coaches and healthcare providers (including mental health providers) will use shaming techniques in order to try to motivate people to lose weight. As mental health professionals, we know shame and harassment, is a harmful method in trying to motivate people to change. Furthermore, weight loss is not a behavior, it is a biomedical marker like blood sugar or cholesterol.
There are several psychosocial and medical consequences of weight-bias. Chronic stress is a consequence for anyone who experiences bias or stigma. It is the same with weight-based victimization. The psychological consequences of weight-bias include an increase vulnerability to mood disorders, low self esteem, poor body image and suicidal ideation.
Studies show the health consequences weight-bias include increase in eating problem including disordered eating (ie. purging and binge eating, severe dieting), avoidance of exercise, increase in stress which leads to higher blood pressure and higher body weight. Additionally, in children who experience weight-based victimization, there is a decrease in academic success.
Considerations When Working with Clients in Larger Bodies
As mental health providers, we have been trained to look at our own bias that we bring into the consultation room.
Here are some tips to help you work more effectively and ethically with clients living in larger bodies:
Assess your own beliefs about your own body.
Assess your beliefs and attitudes about people living in larger bodies. Challenge assumptions.
Assume your clients have experienced weight-based bullying and stigma. Ask clients about their own experiences with weight-based bullying, bias and stigma.
Ask your clients what is like for them to access medical care.
Screen clients for eating disorders.
Do not recommend or encourage dieting as it is an ineffective intervention and harmful.
Use language like “larger body” and “size diversity” vs. “obese” or “overweight.”
See resources listed below to learn more about size diversity and health promotion (vs. weight promotion).
Association for Size Diversity & Health
The Binge Eating Disorder Association
“Health at Every Size” by Dr. Linda Bacon
“Intuitive Eating” by Evelyn Tribole and Elyse Rech
Center for Food Policy and Obesity
Davis-Coelho K, Waltz J, Davis-Coelho R. Awareness and prevention of bias against fat clients in psychotherapy. Professional Psych-Research & Practice. 2000; 31(6): 682-84.
Puhl RM, Latner JD, King KM, Luedicke J. Weight bias among professionals treating eating disorders: Attitudes about treatment and perceived patient outcomes. International Journal of Eating Disorders. 2013; 00:000-000.
Puhl RM, Peterson JL, Luedicke J. Weight-based victimization: Bullying experiences of weight loss treatment-seeking youth. Pediatrics. 2013; 131(1): e1-e9.
Roehling MV, Roehling PV, Pichler S. The relationship between body weight and perceived weight related employment discrimination: The role of sex and race. Journal of Vocational Behavior. 2007;71:300-318.
Weight Bias a Social Justice Issue: A Policy Brief. 2012 UConn Rudd Center for Food Policy & Obesity.
Alison Pelz a psychotherapist and has been a registered dietitian for more 16 years specializing in the treatment and prevention of body image disturbance, eating disorders and other fitness and weight-related concerns. Currently, she maintains a private practice in Austin, TX. You can connect with her on the web at www.alisonpelz.com or follow her on Facebook https://www.facebook.com/alisonpelzcounseling/.