Weight Stigma Q&A

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

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/

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/

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

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)

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.

This list of resources is not meant to be exhaustive. If you work in this area and make use of other great resources, please be in touch with the CDBC at practice.advisory@collegeofdietitiansbc.org as we’re interested in sharing them.

Association for Size Diversity and Health (ASDAH). Health at Every Size ®

Balanced View: Addressing Weight Bias & Stigma in Health Care

CDBC Trauma Informed Practice Q&A

Dietitians of Canada Statement Against Weight Stigma

Holland Bloorview Kids Rehabilitation Hospital: Weight-Related Conversation Resources

Eliminating weight stigma – guidelines for BDA communications | British Dietetic Association (BDA)

Inclusive Language For Higher-Weight People (substack.com)

PEN: Practice-based Evidence in Nutrition. Obesity Practice Toolkit.

Dietitians of Canada Statement Against Weight Stigma

Obesity Canada – Health At Every Size (HAES) Framework

People-First Language – Obesity Action Coalition

Rathbone, J.A, Cruwys, T., Jetten, J., Banas, K., Smyth, L., Murray, K. (2022). How conceptualizing obesity as a disease affects beliefs about weight, and associated weight stigma and clinical decision‐making in health care. BJHP.

University of Connecticut: Weight Bias & Stigma

Weight Inclusive Dietitians in Canada (WIDIC) shared resources