Our policies and public health approaches to weight often focus on two behaviours as the key. What do they miss when they do this?
Eat less and exercise more: this is the core way people in Canada talk about bodies and body fat. We tend to believe that body weight and composition is highly malleable and under individual control. This mantra creates trouble for us, individually and collectively.
Much public health and health promotion work in Canada tries to entice Canadians to change everyday routines. Over time, we’ve learned of many problems with this approach: making major changes in our lives is hard, and the people who are most successful tend to those with the most resources. This increases the health gap, and uses limited public health funds to help those who least need it.
But that isn’t the only effect: the messages of risk and individual control embedded in enticements to change behaviours can lead to guilt and worry for those who cannot make major changes, and blaming of those with health conditions deemed preventable. The result is less attention to other types of policy solutions that improve health.
"Anti-fat stigma is hazardous to health."
Our common ways of approaching weight falls into these same traps. Weight is not as malleable as is often believed. If decades of weight loss research have taught us anything, it’s that sustained, major weight loss through changing eating and exercise is rare. Instead, the effects of behaviour changes on weight, specifically, are usually modest. Changing how we eat and move have many other benefits, of course, but major weight loss is not one for most people.
We run into another kind of trouble if we are stuck in the story that our bodies are under our individual control. Our misguided beliefs that everyone can be thin if they ‘just try hard enough’ implies that people in bigger bodies have poor self-control, are unknowledgeable, or not invested in their health. These beliefs are core to what is called anti-fat stigma. And anti-fat stigma is hazardous to health.
"Stigma must be considered for any successful way forward in the obesity conversation."
Being on the receiving end of judgment, scorn, and blame adds both psychological and physiological stress to people targeted by these messages. And if our health care professionals get stuck in this story about weight, it may result in avoidance of health care appointments, as well as poorer quality of health care (e.g. delayed diagnosis of medical conditions, and thus, delayed or even denial of access to needed care). This is just one way through which misunderstandings about weight worsen people’s well being. The same happens in other sectors, such as education and employment.
Canada’s latest policy report on obesity sought to create ‘a way forward’ for policy makers and public health leaders in Canada. But the report failed to recognize that stigma is part of the problem — and stigma must be considered for any successful way forward in the obesity conversation. The report’s authors are also stuck in this story — and they risk perpetuating the problem.
Humans, like all mammals, are products of our environment. (And our politics).
Eighteen of the Senate report’s 21 recommendations focus on changing the diets and physical activity levels of Canadians. The remaining three are about stakeholders and coordination. Many of these recommendations seek to influence health behaviour by working on the environment.
This is a helpful shift away from the focus on individual willpower as the reason for increase in body weights of the Canadian population. It allows for a consideration of broader environmental contributors to health and fitness like advertising, physical design of communities that can discourage physical activity, or reliable access to nutritious food. But the report perpetuates the dangerous notion that behaviour is the most important factor, and the only factor we should address. For the future health of our communities, we have to stop focusing on personal behaviour, and start looking to political action.
"We need to shift toward a healthier society across all sizes."
If eating and exercise behaviours are the only recognized influences on weight and body composition in health policy, and if environmental changes are made but people remain visibly fat, blaming and shaming people for their bodies will continue. The negative health effects of stigmatisation will continue.
And if environmental changes - such as reducing food advertising to children and improving access to physical activity programs - spur more nutritious eating and an increase in physical activity but do not produce widespread weight loss, policies might be deemed a failure when the issue is a misrecognition of determinants of weight. Health care and health policy that build on these ideas lead us astray.
The way forward must also include awareness that blaming and shaming people for their size and shape may not facilitate healthy outcomes. An explicit commitment to opposing stigma is needed as part of a comprehensive and workable population health strategy.
"Policy making that avoids behaviourism and fat shaming people is likely to support overall population health better than our current approaches."
We need to shift toward a healthier society across all sizes. In practice, this means promoting healthy behaviours separate from talk about body weight. It means disrupting simplistic messages about weight, such as ones that imply that weight loss is always achievable or desirable, and the myth that weight gain and loss are about nothing more than ‘calories in, calories out’. It requires deliberate acknowledgement of anti-fat stigma as a health issue and population health threat.
Our policy makers can utilize determinants of health and health equity analyses when evaluating proposed or existing public health strategies, to avoid pursuing strategies that will worsen inequities. These approaches can support and accommodate the diversity of bodies without stigmas. Policy making that avoids behaviourism and fat shaming people is likely to support overall population health better than our current approaches.
Patricia Thille is a post-doctoral fellow at the Wilson Centre, a joint centre of the University of Toronto and University Health Network. She is a physical therapist with a PhD in Sociology. Dr. Thille works to reduce health disparities that result from stigmatization, exclusion, and discrimination.
This blog is an adapted version of a published peer-reviewed commentary:
Thille P, Friedman M, Setchell J. Weight-related stigma and health policy. CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne. 2017;189(6):E223-e224.
Dr. Thille thanks her CMAJ co-authors, Drs. May Friedman and Jennifer Setchell.