Weight/Obesity

Background


Weight Stigma Background 

 

Contributors

Importance of Topic to Practice
Weight bias refers to having negative attitudes towards and beliefs about others based on their body weight, shape and/or size (1). These biases can be perpetuated by stereotypes and/or judgments and can lead to weight stigma and discrimination (2), as well as contribute to internalized weight bias or self-stigma, which has been shown to have a negative impact on health outcomes, regardless of weight status (3). There has been a significant increase in the prevalence of weight stigma in the United State (4,5) with evidence of weight bias existing in Canada, the U.K., Australia and Iceland (6). Weight bias continues to be influenced by the dieting industry’s idealistic view of 'health', the desire for thinness, and achieving weight loss goals (7-9). In addition, health care professionals (10) and public health/media messaging have upheld the belief that weight is entirely within an individual's control (11,12). Furthermore, studies have demonstrated the negative impact weight bias, stigma and discrimination can have on a person’s social identity (13,14), access to health care and treatment, employment, education (4,5,14-16) and mental health (14,17). As the evidence in this background paper suggests, there has been a shift in understanding of what contributes to weight stigma (i.e. shifting from a BMI alone standpoint of defining obesity to a health-centric understanding of body weight from critical and dominant paradigms.) This shift has led to dichotomizing views and confusion among the scientific community, the health care field and the public. This is of relevance to dietitians in practice, as a lack of awareness of this shift can create unintentional weight bias or stigma that may impact client-provider relationships, nutrition counselling/treatment goals and negatively affect clients and the dietetic profession as a whole. Note: Readers are encouraged to test their own implicit bias towards body weight by completing the Implicit Association Test (IAT) for weight prior to reading this background.

The overall aim of this background is to provide information, challenge assumptions and create bridges for greater collaboration among dietitians and other health professionals across different perspectives in the field of weight stigma. This background summarizes evidence on weight stigma from both critical and dominant perspectives, with the primary goal of minimizing harm while promoting health and well-being for people of all weights and sizes.
 
Topic Overview
Prevalence of Weight Stigma
Weight stigma is the labelling and stereotyping of individuals based on their body weight, shape or size, stemming from negative social attitudes (weight bias) that leads to prejudice and (weight) discrimination (18,19). Individuals living in larger bodies are often characterized as lazy, lacking will-power, unmotivated, sloppy, overeaters, inactive and as having poor self-control (5,20-22). Not only has weight discrimination increased, but the intensity of the discriminatory experiences has also increased (4). The rise of negative societal attitudes about higher body weight is in part due to negative portrayals in the media, popular culture, public health messaging and is exacerbated by the dieting industry (5,23,24). Note: The diet industry is beyond the scope of this backgrounder paper. For additional information, see: Weight Bias in the Media: a Review of Recent Research and The First Amendment and Diet Industry Advertising: How Puffery in Weight-loss Advertisements Has Gone Too Far
 
Populations Affected by Weight Stigma
Children, especially larger bodied children, are vulnerable to weight stigma as weight-based bullying is the most common type of bullying in schools (25,26). In addition, a qualitative study found that teachers perceived students with larger bodies as more likely to struggle academically, to have poorer nutrition habits, to have more screen time and to be less active (27). Weight stigma poses negative consequences for children’s psychological, social and physical health (28), and longitudinal research has found associations between childhood weight-based bullying and disordered eating patterns (29).

Weight stigma disproportionately impacts more women in comparison to men (30). Women with larger bodies with fertility issues or who are pregnant face increased weight stigma; women have been denied fertility treatment solely based on weight and have been judged as unfit to mother (31). Larger-bodied pregnant women are often encouraged to not gain weight or even encouraged to lose weight during pregnancy (32), despite that these recommendations contradict current pregnancy weight gain guidelines (33). Most of the research regarding women with larger bodies in the prenatal period explores their interactions with doctors (34,35), while limited evidence exists for pregnant women with larger bodies working with dietitians (36). Larger-bodied pregnant women have shared their experiences of dietitian advice that ranged from helpful to patronizing (36). Further research is needed to fully understand the experiences of pregnant women with larger bodies who have seen dietitians and to determine how dietetic counselling during this life stage could be improved.

Research indicates that queer women and African-American women are increasingly being targeted by fat-shaming messaging (37,38). Lesbian women (37) and African-American women (39,40), in comparison to non-lesbian and Caucasian women, respectively, have been found to have greater body acceptance at higher body weights; however, public health interventions have targeted these groups as being “higher risk for obesity” (37,39). Other researchers regard this targeting as further marginalizing already marginalized women and recognize body acceptance (at any weight) as a health-promoting, protective factor (37,39). Similar to research on the health impacts of racism (41,42), weight stigma research shows correlations of ill health to experiences of stigma (43). For these reasons, it is important to be aware of how sizeism intersects with homophobia, racism and sexism, as without such awareness, there is the risk of unintentionally contributing to multiple forms of discrimination.

In Canada, there has been increased attention to the rates of overweight and obesity among Indigenous populations where Indigenous individuals are found to have higher weights than non-Indigenous individuals (44). A 2015 review by Kolahdooz and colleagues suggests these higher rates are connected to the transition away from traditional foods and activity patterns among Indigenous Peoples in Canada (44). Rather than highlighting the differences in obesity rates suggested by Kolahdooz and colleagues, Mitchell and Maracle suggest the health and social inequalities between Indigenous Peoples and non-Indigenous individuals in Canada (regardless of body weight) can be connected with the intergenerational trauma caused by colonization of Indigenous Peoples (45). Similarly, a qualitative study regarding views of larger-bodied Maori Indigenous People of New Zealand identified that the emphasis on individual approaches and personal responsibility, in regard to body weight or obesity, was linked to the history of colonialism and seeks to further marginalize Indigenous peoples (46).

Where Does Weight Stigma Occur?
Weight stigma occurs across society including but not limited to health care settings, housing, schools and workplaces (4,5). Observational studies report weight stigma is most frequently perpetuated by family members, doctors, classmates and salespeople (47). Health care professionals such as physicians, nurses, dietitians and exercise professionals have been found to have high levels of weight stigmatizing views (10,48,49), specifically attitudes and beliefs that individuals with higher weights are personally responsible for their weight (50-52). These views have resulted in poorer care for individuals with larger bodies whereby less time is spent, less referrals are made, less treatments are given and individuals avoid health care due to these past experiences (16).

A 2015 systematic review found that dietitians hold less weight stigmatizing views than their health care professional peers (53); however, this is not consistent globally across the dietetic profession (49,54-56). Weight stigma is pervasive in all areas of society, touches all areas of health care practice and impacts health equity (57). In addition, previous reports have found that dietitians are subject to internalized weight bias themselves (58). While there are no published studies regarding patient/client perceptions of a dietitian’s body weight, an observational study surveyed 226 participants’ perceptions of physician's weight (59). Results indicated that participants reported greater confidence with health advice from thinner physicians compared to larger bodied physicians (regardless of the participants weight) (59). Contrary to this, Bleich and colleagues found participants (with a BMI ≥25 kg/m2) trusted their physician regardless of body weight but preferred to receive diet advice from larger bodied physicians more than thinner physicians (60). Because weight bias may be implicit, it is important for dietetic students and dietitians (e.g. dietitian educators, researchers, policymakers, clinical dietitians, dietitians in industry, etc.), to be aware of their own biases, weight stigma and how to decrease its prevalence.

What Contributes to Weight Stigma?
A number of factors contribute to weight stigma (Table 1). One factor is the misconception that body weight is entirely within one’s individual control (61). Public health messaging and global health care education has been historically rooted in individual responsibility with an “eat less/move more” recommendation for weight control (13). However, recent discoveries in body weight physiology and genetics has changed the understanding about how and why the body is unable to utilize a negative caloric intake to sustain weight loss long term (61-65), as well as the heterogeneity of body weights and responses to weight change (66,67). Weight loss can induce a neurobiological response in the brain to defend against weight loss (or a reduction in adipose tissue) by increasing appetite and hunger, while reducing metabolic energy requirements (61,67). This limited understanding in academia and in health care, misguided messages from media and the dieting industry (5,68), in addition to the list of factors provided in Table 1, all contribute to weight stigma.  
 

Table 1: Factors Contributing to Weight Stigma 
  • Individual responsibility of body weight 
  • Misinformation/outdated information about pathophysiology of weight regulation 
  • Lack of trained health care professionals 
  • Media/weight loss industry
  • Using BMI as an individual indicator of health 
  • Lack of access and/or denial of screening, testing and treatments based on weight and body size 
  • Public health messages for weight management 
  • Fear-driven public health messages (“obesity epidemic”, children’s “obesity crisis”) 
  • Lack of laws/policies to prevent weight stigma
 Adapted from (5,68). 

Health Impacts of Weight Stigma
As noted above, weight stigma can have a direct impact on a person’s ability to seek and receive adequate and timely medical care (16,69). A narrative inquiry of the lived experiences of people self-identifying as “living with obesity” revealed experiences of external weight stigma by health professionals that resulted in unjust treatment and medical misdiagnosis/delayed diagnosis (e.g. cancer) (13). Psychologically, internalized weight stigma has a strong negative relationship with mental health (14), increasing the risk for depression/anxiety (17), low self-esteem (17), suicide ideation/suicide attempts (70), and disordered eating behaviours and eating disorders (71). Self-reported data reveals nearly 79% of women with higher body weights disclose eating more food as a coping mechanism of being stigmatized for their weight (47). Physiologically, emerging evidence suggests that weight stigma can elicit a stress response with increased release of cortisol, C-reactive protein and increased blood pressure (18,72), that has been associated with central adiposity and type 2 diabetes (73). Regarding increased body fat, two review studies noted direct causal relationships between stress and increased abdominal fat (74,75). Due to the multiple impacts of weight stigma on physical, emotional and social well-being, interventions based on high quality research are needed to decrease weight stigma.

Relevant Basic Information
State of Shifting Paradigms: Dominant and Critical
Weight stigma can be viewed from different paradigms; a dominant (weight-centric) approach, a health/complication-centric approach and critical (non-weight centric) approach. Despite dichotomizing views and opposing approaches, there appears to be a shift in the dominant (weight-centric) paradigm acknowledging the stigma and discrimination endured by people of all weights and body sizes (76). As such, some of the changes have resulted in a spectrum of views to understanding body weight; some in line, some overlapping and some opposing.

The Dominant (Weight-Centric) Approach
In this approach, obesity is understood as a modifiable risk factor for chronic diseases and weight loss is recommended for people are classified as "overweight" and "obese" to achieve improved health status and/or to revert to a normal/healthy body weight or body mass index (BMI) category (1,2). Traditionally, this approach has focused on definitions of health based on the vast epidemiological literature on BMI and health risk factors (77-79) and has not acknowledged the diversity of body weight as an aspect of normal human variation, similar to height or skin colour. Public health messages and clinical practice have historically emphasized an “eat less/move more” mentality (13). The dominant/weight-centric approach tends to use messages rooted in fear, shame and/or blame in efforts to motivate people to reach normal/healthy body weights according to traditional BMI measurements (80).

Obesity Paradigm Shift (Towards a Health/Complication-Centric Approach)
The dominant/weight-centric approach has changed with the reclassification of obesity as a chronic disease (81-83) as opposed to a lifestyle risk factor for chronic disease. In 2013, the American Medical Association (84) resolved that obesity (defined as abnormal or excess adipose tissue impairing health) is a chronic disease, which has been accepted by other organizations, including Canadian and European organizations (82,84-87). With this reclassification, the dominant/weight-centric approach has shifted to acknowledge the deleterious impacts of weight stigma, the biological and physiological drivers of weight change, environmental and psychosocial contributors, including social determinants of health, as well as the inaccuracy of BMI as a primary indicator of individual health (88,89).
 
This updated health complication-centric approach focuses on adipose tissue dysfunction and its impact on health (metabolic, functional and/or mental health), similar to other organ-specific diseases such as diabetes, chronic kidney disease or heart disease. Specifically, the focus is to assess the type of adipose tissue, distribution and function, with the intention to provide clinicians with individualized treatment options that are independent of weight or BMI (89). The intent is to ensure that body weight and BMI are not sole indicators for the diagnosis of obesity. Therefore, within this approach, some people of lower body weight/BMI may be diagnosed with obesity (as defined by abnormal or excess adipose tissue that impairs health) whereas, some people of higher body weight/BMI would not be diagnosed with obesity as their adipose tissue may not be impairing their health (90). This narrative further intends to support body diversity and a focus on health-related behaviour changes that are universal across all body weights, sizes and BMI categories, rather than targeting healthy eating and physical activity messaging predominantly to people with larger bodies or higher BMIs (80).

Further to this shift in understanding the term "obesity", it has been suggested that defining obesity as a disease requires a change in diagnostic measures (89-92). Research has shown that BMI alone does not indicate or measure one’s health status (93-95), rather has shown an association between higher BMI categories and poor health outcomes (77-79). If definitions of obesity were to change, BMI cut-offs would no longer be used as a lone diagnosis criteria for obesity but rather continue to be used as a screening  tool. Measuring one’s health would therefore include a comprehensive clinical assessment that encompasses an individualized holistic interview, assessing symptoms, physical findings, laboratory testing and/or diagnostic imaging that is similar to how other diseases are determined, which emphasizes a health-based approach to obesity rather than a weight-centred approach (90).
 
This approach is starting to influence a number of organizations to use assessment criteria like the Edmonton Obesity Staging System (EOSS) (96) or the King’s criteria (94), which measure medical, mental and functional health rather than only weight, BMI or body shape on an individual basis. A 2019 study using EOSS adapted for a pediatric population found that EOSS was superior over BMI at assessing physical and psychosocial health issues, which reduces the risk of underestimating and overestimating health risks (93). (See Additional Content: Should body mass index (BMI) be used to evaluate the impact of school nutrition interventions?). Weight bias and/or weight stigma may be reduced by specifically evaluating physical, mental and social well-being as they relate to adipose tissue/body fat impairing health while decreasing the focus on body weight, BMI or body size (90,97). Table 2 provides an example of how this shift in understanding of obesity could be applied in clinical practice.

Other organizations have proposed new diagnostic terms in place of obesity, such as “Adiposity-Based Chronic Disease or ABCD” (89) or “Adiposopathy” (98). However, there is limited quality scientific evidence and clinical approaches to define at what point adipose tissue may be classified as excess or at what point body weight can be said to cause physical, mental and social impairment. As such, the 2013 American College of Cardiology and the American Heart Association Obesity Guidelines (99) and the American Association of Clinical Endocrinologists Guidelines (91) have moved towards a complications-centric approach, rather than a BMI-centric approach by removing BMI as a diagnostic tool and suggesting that BMI be used as a screening tool at population-based levels for which it was originally intended. Similar to the approach proposed above, this would require extensive global collaboration to create changes in epidemiological studies and foundational education (88), which may pose difficulty in the short term.  

Critical (Non-Weight-Centric) Approach
Critical approaches were developed as a response to the dominant (weight-centric) messaging, to challenge approaches and views that contribute to weight stigma and result in health inequities (100,101). Critical approaches aim to raise awareness of body diversity, the impact of weight stigma on health and well-being, including weight cycling, (75,102), and how weight stigma intersects with other social determinants of health (100,101). (See Additional Content: What is the evidence for adverse health effects of multiple periods of weight loss followed by weight regain (i.e. weight cycling, yo-yo dieting?). Furthermore, critical approaches aim to prevent/treat health issues through the lens of health equity and social justice, in addition to individual health behaviour changes.
 
Literature from within the critical bodies of knowledge have illuminated the inaccuracy of BMI as an individual indicator of health status (78,103-106). In addition, critical literature has pointed out that a weight-centric approach has resulted in a “shadow epidemic” of weight-based discrimination as well as eating disorders (107). Some of the critical bodies of knowledge that describe weight stigma include but are not limited to: Critical Weight Studies/Sciences (108), Fat Studies (109) and Critical Dietetics (110). Although these bodies of knowledge bring unique perspectives to understanding body weight and health, what they have in common is a critical approach to this area of study. When a viewpoint is labelled "critical", it can be seen as negative; however, Atkins notes that Anderson describes critical perspectives as a way to understand: “underlying assumptions and beliefs about issues related to professionalism, and in collaborating to minimize the inherent challenges and problems” (111).

Within the critical paradigm, there has been clear opposition to the reclassification of obesity as a disease by weight stigma researchers, experts in the field and by international associations that promote body weight acceptance and seek to end weight stigma (112). Critical scholars, scientists and health care providers do not support the obesity as a disease approach and propose that the term "obesity" be changed or not be used (113). They identify obesity as a medicalized term that may lead to further marginalization of those with larger bodies (114). Further, critical scholars believe fatness or higher weights to be a part of the natural diversity of body size (115); body weight when viewed as a health problem, whether a risk factor for disease or a disease itself, is an example of the medicalization of body weight within critical frameworks. Thus, it is understood that health care professionals who use critical approaches recognize and understand that not every person with a larger body is free of health issues and that they may require medical nutrition therapy to improve or treat their health issues. Furthermore, irrespective of weight, critical practitioners focus on health behaviour changes for treating common health conditions such as diabetes, hypertension and heart disease. See Table 2  for an example of how a critical approach would be used in a clinical encounter.
 
Table 2: Overview of Paradigms 

To further explain the shift in definition of obesity, here is an example of how two people with the same BMI and age would potentially be viewed across all the paradigms. 



Dominant (Weight-Centric) Approach
“Obesity as a lifestyle risk factor” 
Health 
(Complication-Centric) Approach
“Obesity as a chronic disease”
Critical 
(Non-Weight-Centric) Approach
“Fatness as a body size”
Person A 
  • BMI 42 or class III obesity
  • Hypertension, type II diabetes, sleep apnea, fatty liver disease, gastroesophageal reflux disease, osteoarthritis
  • Mobility declined
  • Recommended to lose weight
  • Goal to reach “healthy/normal weight” according to BMI classifications
  • Measure changes in weight, BMI, co-morbidities.
  • EOSS 2
  • May benefit from treatment* because their adipose tissue is impacting their health (conduct 5As)
  • Goal is to improve QoL, health and prevent further complications to medical conditions.
  • Measures may include: weight, body composition, WC, BMI, physical, mental and functional health.
  • Treat the multiple medical conditions to improve health, QoL and prevent further complications via health behaviour change strategies.
  • Focus on health outcomes, not weight (although weight loss may or may not occur).
Person B 
  • BMI 42 or class III obesity
  • EOSS 0
  • Would NOT likely benefit from treatment* but could benefit from health behaviour changes to prevent health-related issues. 
  • Using a BMI-classification alone could result in weight stigma.
  • Metabolically healthy individual living in a larger body
  • Could potentially benefit from health behaviour change to prevent the development of health issues.
  • Assuming unhealthy behaviours based solely on their BMI would contribute to weight stigma.



*Treatment (obesity management) may or may not include weight-loss or weight-focused interventions.  

The Dominant (Weight-Centric) Paradigm would assert that person A and B would both benefit from weight loss despite person B not having any health or quality of life impacts. 

The shifting dominant paradigm, Health/Complication-Centric Approach of obesity management, would suggest a comprehensive clinical assessment (using the 5As, EOSS or King's Criteria, measuring metabolic markers for their health conditions and assessing their social determinants of health) for both persons. Person A could benefit from treatment because their adipose tissue is impacting their health. Person B would not as there are no health conditions to treat; therefore, health behaviour change to prevent the development of future health issues could be considered. Hypothetically, if a person C were presented with all the clinical presentation features as person A but had a BMI of 18.5-24.9, they could benefit from treatment because their adipose tissue is impacting their health. As mentioned earlier, better diagnostic testing and measures are needed to clearly assess adipose tissue and its impact on a person's health, rather than using weight or BMI alone. 

On the other hand, the Critical (Non-Weight-Centric) Paradigm would question the erroneous assumptions being made in this example, and would approach care in a different way; Person A, whose weight has not been established as the cause of their co-morbidities, would be treated for their multiple medical conditions to improve health and quality of life and prevent further complications, with a focus on health not weight. Person B would be considered a metabolically healthy individual living in a larger body, who could potentially benefit from health behaviour change to prevent the development of possible future health issues. However, assumptions made about Persons A and B based solely on their BMI could contribute to weight stigma across all paradigms. Hypothetically, if a person C were presented with all the clinical presentation features as Person A but had a BMI of 18.5-24.9, the critical paradigm would focus on treating Person C for their multiple medical conditions to improve health and quality of life and to prevent further complications, regardless of weight. In addition, with Persons A, B and C, attention would be paid to the social determinants of health.



Reducing Weight Stigma
Weight stigma reduction interventions have been reviewed and found that while there is overwhelming evidence that negative attitudes exist among health care professionals and the public, there is limited evidence on effective strategies to reduce weight stigma (14,68,116). Studies continue to emphasize that if the public and health care professionals understand the multiple factors that influence body size diversity and weight gain, they may have less negative attitudes towards larger bodies and may no longer believe that weight is solely within one’s personal control (117). Studies suggest that incorporating weight sensitivity training into medical/health professional curricula reduces explicit weight bias (118), provides support for individuals (119) and improves access to treatment(s) (120). More so, defining obesity as a disease has been heavily debated as a strategy to reduce weight stigma for those of higher weights (97). Despite critical scholars' opposition to this definition, some studies have shown positive public reception to the obesity as a chronic disease framework (83,88,121). A 2019 cross-sectional study of 400 Canadian family physicians found that weight bias decreased among physicians when obesity was perceived as a chronic disease (122). In addition, 65.5% of the physicians were aware that the Canadian Medical Association has declared obesity a chronic disease and 63.8% agreed that obesity is a chronic disease (122). Similarly, Nutter et al. found that considering obesity as a disease predicted lower weight bias and decreased blame among a general sample of 309 participants living in the U.S. and Canada (88).
 
In Canada, an online weight stigma reduction program developed for health care professionals, called Balanced View: Addressing Weight Bias & Stigma Reduction in Health Care, was launched in 2015 (123). A preliminary case study showed reductions in weight stigma among participants (123). In 2019, Alberta Health Services (AHS) launched the first Bariatric Friendly Hospital Initiative in Canada with the goal to reduce weight bias by improving patient/client experiences and staff training for individuals with bariatric needs (124). Although promising, there is a lack of methodologically strong evidence to support the effectiveness of interventions to reduce weight stigma long term (116). As such, many health care professionals, researchers, policy makers and the general public (in both the dominant and critical fields) are predominantly unaware of the changing definitions of obesity, and research remains premature as to whether adopting obesity as a disease will significantly reduce weight bias and stigma long term (83,121). Efforts to influence individual and societal change start with systematic approaches, including policy and legislation interventions, education, collaborative initiatives and practice-based approaches.

Regulatory Issues 
Weight Discrimination Laws and Protection
There is growing public support for laws to decrease weight discrimination as evidenced by survey data (125) and online public movements such as #SizeismSUCKS (126). The U.S. State of Michigan has included protections for weight in its civil rights law, which protects those who face discrimination in employment since 1977 (127). The state of Victoria, Australia includes “physical features” as a protected characteristic under their human rights code, which refers to a “person’s height, weight, size or other bodily characteristics” (128). The Province of Manitoba, Canada (129,130), and the U.S. state of Massachusetts (131) have proposed such laws. Some municipal jurisdictions have included protections on height, weight, physical characteristics and/or personal appearance (123,127) physical features (Australia) (132) and body build and type (Iceland) (133). No countries to date have a national weight discrimination law; however, Iceland (134), Israel (135) and the Philippines (136) have proposed such laws.
 
There is limited evidence on the impact of human rights law that prohibits weight discrimination; however, a 2017 experimental study of 214 participants of higher body weight revealed that when they are aware of legislation that protects individuals based on weight (i.e. Michigan has an anti-weight discrimination law), their internalized weight bias and psychological well-being improved (76). More so, overt forms of weight discrimination appeared to decrease in the state of Michigan, which has had an anti-weight discrimination law for over 30 years. For further review of anti-weight discrimination and legislative policies, see: Weight Bias and Stigma: Public Health Implications and Structural Solutions.

Collaboration Between Dichotomizing Approaches
Across dominant and critical paradigms, scholars working in the weight stigma field call for moving away from a weight-centric focus and embracing body size diversity, better treatment access and respect for all people, regardless of body size or weight (57,90,102,137,138). There is, however, disagreement among dietitians and other professionals as to the best practice approach for reducing weight stigma. These approaches have been defined by Nutter et al, as weight-centric, non-weight-centric or Health at Every Size® approaches (137). Other scholars use terms such as weight-normative approaches and weight-inclusive approaches (76). For the purposes of this backgrounder, Nutter et al’s, 2016 descriptions have been adapted by merging non-weight-centric with Health at Every Size® definitions to be referred to as the critical/non-weight-centric approach and have included the health/complication-centric approach separately from the dominant/weight-centric approach to reflect the changing views (see Table 3).  
 
Table 3: Overview of Dichotomizing Views on Treatment Approaches to Body Weight  



Dominant/
Weight-Centric Approach  
Health/
Complication-Centric Approach
Critical/
Non-Weight-Centric Approach
Other Labels/
Descriptions
Weight normative; Weight loss; Obesity; Obese; Healthy weights Obesity as a chronic disease; Health-centered; Weight normative and/or Weight-centeredWeight inclusive, Health at Every Size®; Health-centered; Non-diet; Weight neutral 
Bodies of KnowledgeDominant obesity paradigm, epidemiology studies Shifting obesity paradigm, genetic/physiology studies, weight stigma studiesCritical weight studies/sciences, fat studies, critical dietetics
StigmaTypically contributes/causes weight stigma Defines weight stigma as a problem and actively works to prevent it Defines weight stigma as a problem and actively works to prevent it 
Framework
Discusses rates of obesity (BMI and weight focused) Discusses rates of obesity* (for policy change, access to care, education of providers) Frames differing body weights as part of normal diversity of body size
TreatmentTreats obesity (as defined by BMI and body weight) as a lifestyle risk factor and/or may view as a chronic disease Treats obesity (as defined by abnormal or excess adipose tissue causing harm to health) as a chronic disease Does not define obesity as a disease; challenges medicalization of fatness; treats health issues/concerns regardless of weight
Language UsedOverweight, obese, super-obesity or morbid obeseFavours people-first language “people living with obesity” Favours identity first language “fat person” or “fatness”
Adapted from (137).
*Rates of obesity are defined in epidemiological studies based on BMI and not based on the newer definition of obesity as adipose tissue affecting health.



While all of the above approaches focus on the health of individuals, they are heavily debated and lack agreement among dietitians, as well as within other health professions (7). The health/complication-centric approach and the critical/non-weight-centric approach overlap in that they both recognize the physical and social consequences of weight stigma (137). Some Canadian research has found that many dietitians support a non-weight-centric (weight-inclusive) approach, yet many lack the training and skills to implement such approaches in their practice (139-141). A 2019 cross-sectional web-based survey found that weight-neutral (weight-inclusive) approaches were more positively accepted than traditional weight-centric approaches (i.e. weight-loss goals) among a sample of 317 Australian dietitians (142).

Some dietitians may identify strictly as using a weight-centric, a health/complication-centric or a critical/non-weight centric approach, while others may use a variation of any or all these approaches depending on their values/beliefs, their training, their patient/client needs and/or personal preferences in nutrition care. However, Nutter et al. raises a call to action whereby all approaches can meet within a social justice focus to bring unity to these issues as well as advance interdisciplinary research on weight stigma (137).

Practice-based Approaches to Decrease Weight Stigma
As previously discussed, the field of weight stigma/bias includes both parallel and dichotomizing perspectives among clinicians, researchers and the public (Table 3). It is imperative that health care professionals work collaboratively to address weight stigma/bias using evidenced-based and client/patient-centered approaches. Focusing on health instead of weight and consistent messages for health behaviour changes, regardless of weight, have been recommended practice strategies to combat weight stigma (102). This backgrounder will not go into detail about these practice-based approaches to decrease weight stigma as there are many training opportunities available within both the dominant and critical paradigms on how to implement such approaches (See Table 2). See Additional Content: What is the evidence for any comparative difference in health effects of non-dieting or HAES-based interventions compared to a weight-loss approach in individuals with overweight or obesity? 
 
Weight-Inclusive Language to Decrease Weight Stigma
Preferred language for reducing weight stigma has been heavily debated (112,143-147). Patient/client preferences are inconsistent as some studies (primarily surveying participants characterized as “obese”) prefer terms such as “weight”, “weight problem”, “excess weight”, “unhealthy body weight” or “BMI” (147). Additionally, studies have found undesirable terms such as “fatness”, “excess fat” and “obesity” to be stigmatizing (147,148); however, recent studies suggest these factors could be explained by internalized weight bias (149). In recent years, the fat acceptance community has advocated to reclaim the word ”fat” as a neutral descriptor, similar to describing other characteristics such as tall, short, thin, etc. (100,101) while others prefer using "higher weight" or "larger bodied people" as descriptors (100). Alternatively, other groups have advocated for "people-first language" (i.e. describing people living with obesity rather than using the word "obese" or describing people with living with diabetes rather than the word “diabetic") (143,144). Table 4 offers suggestions on language for reducing weight stigma. However, it is important that health care providers be aware of the type of language that clients prefer to use to refer to their body size or whether or not they would like to discuss their body weight.
 
Table 4: Weight-Inclusive Language  



AvoidConsider
Critical (Non-Weight-Centric) Approach 
  • Obesity
  • Obese
  • Heaviness
  • Large size
  • Excess fat
  • Fat/Fatness*
  • Weight
  • BMI
  • Larger-bodied
  • Fat/fatness*
Health/Complication-Centric (Obesity as a Chronic Disease) Approach
  • Obese
  • Morbid obese/obesity
  • Extreme or super obese
  • Weight recidivism
  • Fat
  • People living with obesity
  • Obesity**
  • Weight 
  • Unhealthy weight
  • Weight gain
  • Adiposity/adipose tissue
 *Fat/fatness: While some research indicates some individuals do not prefer to be described using the words fat/fatness (147), critical literature acknowledges how reclaiming fat as a simple descriptor can be empowering for some (100). 
**Similarly, some research supports the term obesity with acceptance among some groups as reclaiming the updated word/term of obesity, as defined by adipose tissue negatively affecting health (143,147,150,151).


 
Conclusion
Shifting definitions of obesity and continued controversy around best practices to decrease weight stigma have led to confusion and challenges, despite attempts to find common ground. While science may advance its understanding of weight stigma, weight change, weight gain and its connections to health, there still may not be agreement on what the term "obesity" means. Furthermore, everyone, including dietitians, are exposed to the same societal prejudices against weight and body sizes. It is therefore inevitable that biases will exist, emphasizing the importance for all health care professionals to be aware of emerging evidence, shifting attitudes and biases within themselves, in their clients and in society as a whole. Nutter et al. stated, “The lack of recognition of the impact of weight-related social discourses may contribute to the oppression of individuals with obesity” (57). The lack of awareness of the evolving beliefs, attitudes, education, research, practice and structures (physical and political) surrounding body weight could add to weight stigma.

There is limited evidence on effective strategies to reduce weight stigma; however, it is imperative that health professionals work collaboratively to address weight stigma. To do this, dietitians can come together to shift the focus from weight loss ideals to health improvements, recognizing the complexity of the biological and environmental influences on body weight and body fat variations for people of all shapes and sizes. Furthermore, implementing compassionate and non-judgmental approaches to body weight concerns including medical situations where medical nutrition therapy, pharmacological and/or surgical interventions may support a person’s health, irrespective of weight loss. Understanding the social inequities that result from weight stigma and how these intersect with other societal prejudices can reduce discrimination of all forms. Recognizing weight stigma as an important social justice issue, researchers, clinicians, educators, policy makers and the public at large can take an intersectional approach to improve health equity and quality of life for those of all shapes and sizes.

Resources for Professionals
Clinical practice guidelines, web links and other professional tools and resources can be found under the Related Tools and Resources tab. Use the Audience, Country and Language sort buttons to narrow your search.

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Target Group: All Adults
Knowledge Pathways: Weight/Obesity, Weight/Obesity - Assessment, Weight/Obesity - Dietary Approaches, Weight/Obesity - Dietary Supplements, Weight/Obesity - Pediatric/Paediatric, Weight/Obesity - Pediatric/Paediatric: Prevention, Weight/Obesity - Bariatric Surgery
 Last Updated: 2019-12-03


Current Contributors

 

Jennifer Brown - Author

Lindsey Mazur - Author

Helen Croker - Reviewer

Jennifer Brady - Reviewer

Judy Bauer - Reviewer

Maria Ricupero - Reviewer

Natalie Stapleton - Reviewer

Paula Brauer - Reviewer