Weight Stigma Q&A

Q1: What is weight stigma?

The inherent association of this term with obesity is illustrated by the World Obesity Federation’s definition: “Weight stigma refers to the discriminatory acts and ideologies targeted towards individuals because of their weight and size. Weight stigma is a result of weight bias. Weight bias refers to the negative ideologies associated with obesity.” [1]

However, it is also important to take into consideration the potential for underweight stigma , as pointed out by the National Eating Disorders Association definition of weight stigma: “discrimination or stereotyping based on a person’s weight.” [2]. This definition doesn’t limit the experiences of weight stigma to individuals in larger bodies; rather there is a recognition that individuals who are underweight can also be impacted.

There are very few studies to measure the treatment of and discrimination against individuals who are underweight. One study notes that women tend to experience a proportional increase in weight stigma with body weight increase, while men experience weight stigma at the extreme ends of BMI, both underweight and obese.[3]

Given the higher prevalence of weight stigma among those living with obesity, as well as the abundance of evidence for this, this Q&A will focus on weight stigma that includes feelings and attitudes established as prejudice, discrimination, and stereotypes towards people that have a higher weight than an average individual. Weight stigma can appear in different forms which can include harassment, bullying, isolation, negative comments regarding weight, and microaggressions [4].

Weight stigma can be linked to two different types of weight bias: explicit and implicit. Explicit weight bias refers to the negative viewpoints of weight that individuals are aware and conscious of. An example of this would be directly linking the diagnosis of type 2 diabetes in a patient to being overweight or the implication that a person experiencing severe underweight or a condition like anorexia can improve simply by eating more. Implicit weight bias refers to the negative viewpoints of weight that individuals are not aware or conscious of.  An example of this would be being concerned for a patient that unintentionally and rapidly lost 10% of their weight when their initial weight was 75 kg but seeing this same outcome as a positive one for an individual that was initially 125 kg.

[1] World Obesity Federation. Weight Stigma. https://www.worldobesity.org/what-we-do/our-policy-priorities/weight-stigma

[2] National Eating Disorder. Weight Stigma. https://www.nationaleatingdisorders.org/weight-stigma

[3] Himmelstein, M.S., Puhl, R.M., Quinn, D.M. (2018). Weight Stigma in Men: What, When, and by Whom? Obesity. https://onlinelibrary.wiley.com/doi/10.1002/oby.22162

[4] The Weight-Inclusive versus Weight-Normative Approach to Health: Evaluating the Evidence for Prioritizing Well-Being over Weight Loss: https://www.hindawi.com/journals/jobe/2014/983495/

Q2: Why is it important to reduce weight stigma? How is weight stigma damaging?
Weight stigma is discriminatory and should not be accepted in today’s society. Weight stigma impairs the health of individuals that face it and also devalues human rights and social rights [1].

Weight stigma is associated with negative characteristics such as laziness or indiscipline. This results in the dismissing of other unmodifiable factors, including genetic, biological, and environmental factors, that can also play a role in the development of obesity [2].

Weight stigma may have many adverse effects on an individual that faces it. This includes but is not limited to depressive symptoms, lower self-esteem, increased anxiety, increased stress, increased risk of substance abuse, and mental health issues such as binge eating and bulimia [3]. Weight stigma is also a stressor that has been found to lead to higher cortisol levels and increased eating as a coping strategy which can cause further weight gain and can be described as a positive feedback loop [2].

Weight stigma also leads to health care professionals, including Dietitians, showing prejudice towards individuals that are overweight. This may cause clients to delay seeing health care professionals in order to avoid facing stigma or misdiagnosis of conditions. Weight stigma in health care settings may lead to impaired health outcomes for clients that are overweight [2].

It is important for Dietitians and other health care professionals to reduce weight stigma within health care settings and their clients’ environment to improve mental health and physical health [3]. To truly practice patient-centered care, weight stigma must be recognized as a barrier to safe, competent and ethical care, and be removed.

[1] Joint international consensus statement for ending stigma of obesity: https://www.nature.com/articles/s41591-020-0803-x

[2] Dietitians and Nutritionists: Stigma in the Context of Obesity. A Systematic Review: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4605484/

[3] PEN: Practice-based Evidence in Nutrition: Weight Stigma Background: https://www.pennutrition.com/KnowledgePathway.aspx?kpid=803&trcatid=38&trid=28010

Q3: What changes can I make to my practice to reduce weight stigma? How will this influence my clients?
Incorporating the issue of weight stigmatization and its consequences into the CCP and integrating your learnings into practice is a crucial step that you can take to reduce weight stigma [1]. Q6 outlines the CDBC practice standards and ethical principles that pertain to addressing and mitigating weight stigma. Dietitians can also seek to improve their knowledge on the association versus causality of weight and chronic diseases. Research has significantly evolved over the years on these topics and being up to date is important to reduce bias.

Weight stigma can also be reduced by ensuring that the healthcare setting, including private practice offices and waiting rooms, has supplies and equipment for clients with different body sizes [2]. You may have influence over your private practice office and waiting room supplies and furniture. Initiating discussions aimed to reduce weight stigma with family members, friends, and significant others is another change in practice that can lead to a reduction in weight stigmatization [3]. Other changes that you can make are to minimize praising weight loss or commenting on weight gain, using weight-inclusive language [3] (for examples, using the terms “higher weight” instead of “fat” or “obese”, and “person living with obesity” instead of “person that is obese”), as well as using a weight-inclusive approach in your practice [4] [5]. See Q4 for more information about the weight-inclusive approach.

Viewing clients that are overweight or living with obesity as competent individuals and reinforcement with positive attributes might increase their desire to seek care and benefit their self-image. Changes such as these are important for clients to improve their weight-related health outcomes [6].

[1] Obesity treatment: Weight loss versus increasing fitness and physical activity for reducing health risks: https://www.sciencedirect.com/science/article/pii/S2589004221009639

[2] Joint international consensus statement for ending stigma of obesity: https://www.nature.com/articles/s41591-020-0803-x

[3] Weight and Healthcare. Inclusive Language For Higher-Weight People (substack.com)

[4] The Weight-Inclusive versus Weight-Normative Approach to Health: Evaluating the Evidence for Prioritizing Well-Being over Weight Loss: https://www.hindawi.com/journals/jobe/2014/983495/

[5] PEN: Practice-based Evidence in Nutrition: Weight Stigma Background: https://www.pennutrition.com/KnowledgePathway.aspx?kpid=803&trcatid=38&trid=28010

[6] Dietitians and Nutritionists: Stigma in the Context of Obesity. A Systematic Review: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4605484/

Q4: What is a weight-inclusive approach and how do I find out more about it?

A weight-inclusive approach is a concept that is based on the belief that an individual can be healthy independent of weight, if healthcare free of weight stigma was provided [1]. It is an approach that challenges the ideology that factors such as weight and BMI are focal points in determining whether an individual is healthy or not [1]. A weight-inclusive approach is one that focuses on self-care behaviours such as eating when hungry, stopping when full, and participating in exercise that is enjoyable [1].

Health At Every Size (HAES) is a model that was designed using a weight-inclusive approach and is used to improve the health of individuals regardless of their body sizes [1] [2]. Intuitive eating principles can also be explored [3]. More resources can be accessed in Q8.

[1] The Weight-Inclusive versus Weight-Normative Approach to Health: Evaluating the Evidence for Prioritizing Well-Being over Weight Loss: https://www.hindawi.com/journals/jobe/2014/983495/

[2] Association for Size Diversity and Health (ASDAH). Health at Every Size ®. https://asdah.org/health-at-every-size-haes-approach/

[3] The Original Intuitive Eating Pros. https://www.intuitiveeating.org/

Q5: What are some barriers in my practice that might prevent me from reducing weight stigma?
Consider your own biases [1], which are formed by previous beliefs, established preconceptions, and fixed viewpoints. Examples may include that:
  • Obesity is mainly caused by overeating and a lack of physical activity
  • Obesity is a choice dictated by lifestyle
  • Obesity can simply be overcome by eating less and more physical activity

All the examples above are incorrect.

External barriers may also impact your effective use of weight inclusive approach [2]. These may include:

  • The media portrayal of weight and its encouragement of weight-based discrimination
  • Healthcare settings lacking sufficient equipment to treat clients who are overweight
  • The use of weight/BMI as the sole indicator for healthy weight and estimated nutrition requirements
  • Lack of workplace policies aimed to reduce weight stigma
  • Weight-loss advocacy by public health associations

[1] Joint international consensus statement for ending stigma of obesity: https://www.nature.com/articles/s41591-020-0803-x

[2] PEN: Practice-based Evidence in Nutrition: Weight Stigma Background: https://www.pennutrition.com/KnowledgePathway.aspx?kpid=803&trcatid=38&trid=28010

Q6: Why is the CDBC speaking about weight stigma? What CDBC Standards of Practice and Ethical Principles apply to minimizing weight stigma?

As explained in Q2, weight stigma may affect dietitians’ judgement and ultimately, client care and outcomes. This directly relate to expectations of practice which are established in Standards of Practice and Ethical Principle.

CDBC Standards of Practice, available on the Quality Assurance Page:

Standard 4. A Dietitian acts ethically in their professional interactions and while providing professional services.

Standard 6. A Dietitian provides information and obtains informed consent prior to the provision of professional services.

Standard 9. A Dietitian communicates in a clear, concise and respectful manner.

Standard 12. A Dietitian provides quality professional services that reflect the unique needs, goals, values and circumstances of the client. Indicators 1-6.

Standard 13. A Dietitian seeks information and incorporates an evidence-informed approach to their practice.

Standard 14. A Dietitian uses critical thinking to obtain assessment data, determine practice problems, plan, implement and evaluate professional services.

Code of Ethics, available on the Quality Assurance Page:

Principle 4. A Registered Dietitian demonstrates inclusion, honesty and integrity at all times when interacting with clients.

 Principle 5. A Registered Dietitian demonstrates respect, dignity and privacy at all times when interacting with clients.

 

ICSH and Anti-Racism Standard:

Core Concept 4. Creating safe health care experiences

Core Concept 5. Person-led care (relational care)

Core Concept 6. Strengths-based and trauma-informed practice (looking below the surface)

Q7: It would be helpful to have some sample CCP goals so I can plan to incorporate reduction of weight bias in my CCP.
We would like to share a few sample learning reports related to weight stigma/bias. You may choose how you would like to develop your learning reports as long as that they comply with the CCP guidelines.

The learning activities section of the learning reports below has not been included. These opportunities can be specific to geographical region, time of year, and community/workplace engagement and can become easily outdated. For more information and to access resources for your learning needs, please see Q8 below.

Example 1

Standard 13. A Dietitian seeks information and incorporates an evidence-informed approach to their practice.

Indicator 2. Assess/ interpret clients’ information/ evidence, considering contextual factors, ethics and client perspectives.

Learning Goal: In this CCP cycle, I will focus on learning and consistently applying the principles of intuitive eating in my private practice, with all clients, regardless of their weight, where these principles suit the client nutrition goals.

Learning Activities:

  • See Q8 for resources and inspiration.

Learning Outcome:

I have been able to promote eating patterns and develop individualized eating strategies based on hunger, satiety, and pleasure, while also focusing on nutrition needs. This approach replaces weight control eating plans I have used for years for clients who wish to lose weight. I have been able to collaborate with clients such that they place emphasis on eating for pleasure and satiety, and referring to clinical counsellors where the interprofessional collaboration improves care, rather than solely focusing on numbers on a scale and calories in a food.

 

Example 2

Standard 10. A Dietitian contributes to the provision of quality professional services as a member of the clients’ interprofessional team.

Indicator 1. Contribute professional knowledge to discussions and interactions with team members using an open, collaborative approach.

Learning Goal: In this CCP cycle, I aim to educate myself on inclusive language use in the context of obesity with a goal to using it consistently in my communications and documentation, such that members of my interdisciplinary team can benefit and learn from my weight inclusive approach.

Learning Activities:

  • See Q8 for resources and inspiration.

Learning Outcome: For many established members of my team, the “old school” train of thought is that obesity is a choice that can be reversed by voluntary decisions to eat less and exercise more. By using inclusive language in my interaction with health care providers, as well as in my documentation, I am placing emphasis on the client first, while avoiding describing the client with weight-related descriptors, in hopes to reduce weight stigma and discrimination that so much of this population has experienced extensively. I am able to speak up confidently when weight biased language is being used when the team is discussing client care.

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