What is weight stigma?
This is the safefood podcast.
Aileen: Hello and welcome to the safefood Nutrition podcast, I'm Dr Aileen McGloin, Director of Marketing and Communications at safefood, the all-Ireland agency promoting food safety and healthy eating. On this podcast we talk about nutrition issues like obesity, food poverty, sustainability and health in the media. Today, we look at weight stigma, how it impacts people's lives, health care and how to tackle this.
On Zoom, I'm delighted to be joined by Dr Grace O'Malley a health professional who leads the Obesity Research and Care Group at the Royal College of Surgeons. Grace's studies focus on clinical, eHealth and public health aspects of pediatric obesity. Also with us is media trainer and former BBC journalist Sarah Travers. With over 18 years in the BBC newsroom, Sarah brings with her the media's perspective. And to talk about how stigma can impact someone's life and health is Patient Advocate, Susie Birney from the European Coalition for People Living with Obesity, welcome everybody.
To start then I'm going to ask you a question Grace, probably what seems like quite a basic one but would you mind explaining what exactly weight stigma is?
Grace: So weight stigma relate to a stereotype or misconception about somebody based on their size or their weight or their shape. Often people with obesity, or who are of larger size, will be treated unfairly because of their size or their weight.
Aileen: And are there any specific ways that it manifests itself in society?
Grace: Yeah, unfortunately, and this has been a growing area of research over the past 10 to 20 years. Unfortunately, we see weight stigma and bias in practically every area of our society so be it in our relationships, socially so in the playground, in schools or at work and or in education, also unfortunately within the healthcare setting so we know from research that multiple health professionals show weight bias and weight discrimination towards their patients who are larger.
Also, it can affect health policy, so often there has been a huge focus on health promotion as a way of treating obesity and the science unfortunately, shows that that's not adequate and that you need actual dedicated treatment systems. They are trying to get funding for those types of systems and health services. That has been very, very difficult and that seems to be that there is this kind of underlying bias around policy and that people are to blame for this themselves so we shouldn't invest in it.
Unfortunately, also within education we know that children, even in primary school, will be treated differently by their teachers if they're of larger size and that can have massive implications for their long term educational achievement. And then in adults also, we do see work that has shown that adults who are of larger size will be treated differently in interviews and their hiring or promotions will be different. And then also within housing, so that landlords are less likely to rent housing to people with obesity.
And another area which can be really damaging for the population at large is within media, so whether it's the use of stigmatising imagery or language, whether editorials or articles are biased, there's a huge role for the media in how the kind of public misconception is graduated and particularly, we've worked within ASOI and Children's Health Ireland at Temple Street with the Irish media around this issue, specifically on using inappropriate images of children so very rarely would you see children with any other condition on newspapers without clothes on or with their heads removed. Usually children would be given - and adults of course - but in relation to children, usually they'd be given the dignity of wearing clothes or having a face.
So it's very widespread and until, I suppose, we'll kind of just keep an awareness of where it is and how it manifests, nothing will change really until we're able to increase that awareness.
Aileen: Grace, you've outlined an enormous range of consequences for people due to stigmatisation of obesity, I'm gonna ask you a question that's quite current, there is evidence of a relationship between obesity and COVID-19 and poor outcomes,. Do you think that this will potentially add to stigmatisation?
Grace: I think so far over the last two weeks and months we've seen that it has, that there has been an increase in how that message has been interpreted by the media and how social media, derogatory comments, memes and comedy skits have kind of covered this. But recently in the last week, the European Commission and the European Centers for Disease Control have actually just announced that obesity will be placed on the medically vulnerable category for COVID-19. So this is very important because it what it means, in effect, is that people with obesity will have to be involved in clinical trials of vaccines or treatments, but also that their treatment shouldn't be deprioritised compared to other patients.
And you know, often worldwide, but particularly in Ireland people with obesity who are trying to get help for their condition can't actually access it, but this is really important in terms of COVID-19 because it's really saying that we have to be able to provide treatment for these patients and we can't deprioritise this due to COVID because they're actually potentially be at an increased risk.
Aileen: Susie if I could come to you now as a woman living with obesity, can you tell us about your personal experience of weight stigma?
Susie: Yeah, I have many experiences of stigma unfortunately in the healthcare and outside of it. I remember one time having my blood pressure checked and the nurse went off to get a different cuff because he didn't believe that at 25 stone my blood pressure could be normal the first time so he insisted on having it done again. And I was at another another appointment one time having my kidneys checked and the nurse prodded the scanning device into my side, giving out to me that I didn't fast at the required time which I had. I actually got a bruise from this, I remember being mortified and leaving that appointment, I actually I didn't go back for my second appointment after that, which was quite hard.
There was another time I think I was queuing for a restaurant one night with friends and the host as we walked in the door said and low voice that we'd have to wait until a table came up that had a seat that I could fit in, and a lot of seats was like American style booths and I was mortified as all the people queuing behind us passed us by to go to tables, while we had to wait particularly for one that would fit me, and do you know as I as I talk about these experiences I'm right back there, I can remember like it was yesterday.
I was working in a timber yard's accounts department one time and one of the trade guys asked as I was passing by through the doorway to go out to the stores, he asked in front of about five customers could I fit through the door and found it very funny as they all laughed and, you know, I just wanted the ground to open up and swallow me. But now as a patient advocate I understand more about stigma particularly self-internalised stigma and I can now recognise that I blamed myself for my problems and actually didn't just blame myself, I think I outright hated myself to the point that it affected everything I did.
And working with other advocates I hear so many similar stories. One of our colleagues Maura, she was passed over for promotion in the Department of Foreign Affairs 20 years ago and the person who held the interview came to her and said, you know, you were the best candidate but if you could just shed some of the weight you would have got it. MF was put on a diet by her mom at age seven because she wanted her to look prettier in her communion dress and another of our advocates, Bernadette was brought one time she had a hospital appointment and she was marched down into the kitchen to be weighed in the packing area because there was no weighing machine that carried her weight at where her appointment was. And I think all of these stigmatising instances they stay with us, you know, they stay with us for life as I said, you're right back there, you know. I think people having obesity have had stigma in some way shape or form nearly every single day, unfortunately.
Aileen: I think we're all appalled listening to those accounts. And Susie what would you say to people who say that obesity is a personal choice, you often hear at this kind of discourse in the media.
Susie: Yeah, you know if it was such a personal choice, it wouldn't be such a multi-million-dollar industry, what is weight loss, you know. I mean, growing up, I ate less than my brother did and he never carried extra weight and I never could understand it. I think it is difficult for the general public to believe that it isn't our choice when even our own GPs don't believe. I had an appointment with my GP one time and after having lost a lot of weight he mentioned that I was regaining and wanted to weigh me, and when were discussing it and I said but that's why obesity is a chronic disease and he replied, oh, no, no, that takes away personal responsibility. And I said, well I've never stopped taking personal responsibility but it doesn't mean I don't need professional help. But you know that was his opinion and I was shocked thinking that, you know, he should be educated on this.
So it is harder than that the wider society will see, but it's a personal choice, our disease is visible for everybody to see so we don't get a day off from it. It's emotionally draining to go out the door some days and I mean, I think it's becoming more out there that there's multiple factors that people who live with obesity could have one or combined reasons like whether it's like psychiatric or environmental or they're on medication or it's genetic, but it's slow that information getting out there. So as it regards thinking about obesity as a personal choice we don't blame people who who get skin cancer or people who get lung cancer through smoking or sitting in the sun, or if somebody breaks their leg from skiing down a slope and they're doing extreme sports and we would never judge them, they go and they get treatment and it's you know, we have to eat and some people have different metabolisms to others and their bodies don't respond the same and it's really far from a personal choice.
Nobody chooses this life, where every day you're stared us or pointed us or asked, do you want to eat that or what size of clothes are you now or if it was down to willpower, there'll be no obesity problems costing every country the money that it's costing.
Aileen: Absolutely, you mentioned the media as a source of bias and even to certain extent health care workers. Where does the bias come from? Is it from peers, friends, family or is it kind of a totality of all of these things?
Susie: It is, I was gonna say it's not or it's all, It's all unfortunately. I mean, if you think as simply as that in Thomas the Tank Engine you've got the Fat Controller, my friends three year old grandson said, Granny how are you fat and he's watching it every day on television. You've got these magazines where on page 18 you're told you're beautiful the way you are, page 19 how to lose weight fast and then page 20 is a cake recipe. So you have the mixed messages. What what are you to believe, you know? But, particularly, too it's quite hard for everybody involved, both the family and the person who's living with obesity, is when it comes from family who don't know that they're doing it.
Aileen: And if you're comfortable Susie, are you happy to outline how weight stigma has affected either your personal journey in life or your mental health?
Susie: Yeah, it's taken me a long time to I suppose get my head around it, now that I'm I'm very involved in patient advocacy I can recognise a lot of it now. So when I think back to that time when I worked in the timber yards and I was in the accounts department, I was pushing for a promotion and they were involving me in work that wasn't directly in my sort of work that I was doing day to day and I got all annoyed and I left. I left the job in a hurry and I think now looking back it was because as soon as I was getting successful at something around, I had no confidence.
It affected everything like that, I didn't believe I could be good at anything, you know, so I walked away from it and it's only now I see that years later. Mental health - I will go through quite a lot of phases of getting low but now I recognise it and I don't, for want of words, try and get myself out of it quicker, I accepted that it's a hell of a lot better and I'm reaching out for help and support but as I am talking to people about it has been huge, I can't share enough about patient support and having been able to talk to your peers about these things.
Aileen: And what do you do now Susie to protect yourself from weight stigma?
Susie: I just avoid situations, I avoid conversations. I think now I have a bit more confidence to say to people sorry I actually don't want to talk about my weight, you know, I wouldn't ask you what your HbA1c levels are if are diabetes or you know, I just actually say I don't want to have that conversation, that you're not a close enough person to me to talk about my weight so I avoid it. It's much harder to avoid social media particularly when something quite big happens we've had a pretty bad on RTE and comic relief and what we did was we actually wrote in letters of complaint and feel like that we've tried our best to raise the awareness about the issue and then ...
Aileen: And Sarah I'm gonna come to you now if you don't mind, as a news journalist with the BBC and in the news room, were you aware of weight stigma and stereotyping based on weight when you were there?
Sarah: Well, that's probably about six or seven years ago since I worked in the BBC newsroom and, okay, so there are two things, there's me as a female newsreader and my own feelings about looking a certain way, that's one thing. And then there's the how we covered issues around weight, I suppose.
So if I go to being a female, first of all on camera from the age of 22 and I was very aware of how much you would be judged about around your appearance and I struggled with that and I would say that a handful lot of my female counterparts did as well. We were never told you need to be a certain size or look a certain way, but there would be little jokes. It was all about the moment on the lips a lifetime on the hips, what are you eating that for and you're in the public eye, and see we're very, very aware all the time that it doesn't matter how good a performance you gave, the great interview that you did or the hard work carried out, it was whether you looked a certain way in the dress or that jacket didn't suit or your your hair wasn't nice or you were tired or whatever and your male counterpart that would have presented alongside you, no one would have batted an eyelid if he wore the same suit two days in a row or wore for a whole week in a row.
But the other side of it is how we covered stories around weight, and I used to front a slot every Thursday evening called Family Focus and I would have covered a lot of stories around eating disorders and and it was very topical in the kind of in the 90s and the early noughties. We've done a lot of stories with the Eating Disorders Association and and it was a growing problem that was was being talked about and it affected so many people, male and female as well, but I would have to say there was definitely probably unconscious bias going on in terms of how we covered stories about obesity. Journalists have had to challenge themselves and think about the way you know, are we honing in on the fact that somebody had to buy two airplane seats, or how did that person feel about having to buy two airplane seats? You know what I mean? So I think we need to start hearing what it's like to have obesity to, to live with obesity and we have a responsibility as journalists to help educate and challenge that unconscious bias and we need to also look at social media and clamp down on the trolls that are out there and the hate that's peddled really, because it's costing lives.
Aileen: Could you comment Sarah on this was the coverage of the topic of obesity in the wider media. I think your experience of BBC is one thing but I suppose there's a whole variety about how different topics are dealt with in a whole variety of media.
Sarah: I think the amount of fake news that is out there is awful as well, I'm a trained BBC journalist, we did not run with the story unless we had two reliable sources and nowadays, there's so much misinformation out there and that I suppose you're relying on individuals' intelligence to think I'm not gonna believe the first thing that I read, I want to read more around that subject. But I still think that people should be putting their hands up and putting themselves forward for interview. I think they should alert a local journalist or, you know, look at their local output and say, yes I'd like to be that dietitian on your programme that could maybe advise on on nutrition, I'd maybe like to talk in this field, I'd like to, like Susie share my experiences. It's always going to be the personal story that people are interested in. So if you can share your personal story in a way that helps change the narrative then it's so useful to do that. So I would say to try and and if you really want to make a difference, please be brave and take part in the conversation, because how else are we going to change what the masses are believing?
Aileen: I'm just gonna ask you all one penultimate question, if you could do one thing and maybe start with yourself Susie, what would you do to change the situation?
Susie: I wouldn't say if I could do one thing, I think I am trying to do one thing with our work with ICPO, which is the Irish Coalition for People Living with Obesity. We're a patient-led group that we are forming to hopefully change the lives for people living with obesity. We were at the moment strengthening support services where we can, or we're trying to educate and raise awareness about the science of obesity so people will stop shaming themselves and blaming themselves, and like Sarah said, sharing our stories and helping people to understand what it's like so then they may stop judging. And I suppose more than anything else in a nutshell to remind people that regardless of our size, we've the same heart, we've the same intelligence as other people and we have the same rights to treatment for our obesity.
Aileen: Absolutely, and if I could come to you Grace.
Grace: Yeah, I think particularly in the area of training and education, I think that's one of the things that really has to improve, so how our health professional students and indeed postgraduates are trained. And like Susie, I've been working with the ASOI so the Association for the Study of Obesity on the Island of Ireland and also the Royal College of Surgeons and Children's Health Ireland at Temple Street to try and improve the training and education of health professionals.
At the moment, we're running some work from the SláinteCare Integration Fund which is really aiming to improve education. Because unfortunately what people may not realise about health professionals, actually on their curricula at undergraduate level very rarely have any training in this area, so you may have one or two hours around general nutrition as a medical student but the specific pathophysiology of obesity, the drivers and the genetics, the neuro endocrinological control of weight regulation, none of those issues really are covered formally, so we really have to improve how we educate our health professionals.
And I think also, along the lines of education and training as well, Sarah and Susie spoke about issues that rely on empathy and respect for one another. So often, there are people who won't really care about the fuzzy-wuzzy aspects of this, and I still think there's a huge argument to support why we should reduce weight stigma for those people, so even if they don't want to use, you know, respectful language with their patients, there's a huge cost and economic argument for still reducing weight bias, because we do know from the literature that that exists, that when patients feel stigmatised they actually have poorer health outcomes.
So even if you don't want to respect people, but you do want to help, you know, improve, reduce cost of health care or improve the efficiency of our health care for taxpayers, it still requires health professionals to just try and be less weight biased and that requires self reflection. So I think that's one thing in addition to training or education and one part of training education is to actually really reflect and most of us, I would say actually all of us are probably biased in some shape or form and hold some judgment against people of a larger size. And as Sarah mentioned and you know why is that and and I believe it's a primal thing and particularly in a country where you've experienced famine and we have very, you know, there's a deep-seated kind of memories around access to resources and food. I do believe that there's very deep-seated experiences and memories within us around why we think of the other in a different way and whether that other is somebody of a different race or a different gender or different sexual orientation or due to different size.
So until we really reflect ourselves, even in simple ways so if we're shopping, if we look in someone else's trolley, do we make a judgment about what's in that trolley and the type of person? If we see a patient and have we already formed an opinion of them based on what shape they are when they come into the room? Or if we're learning about a patient case or a case scenario and we see the word overweight or obese, have we already formed an opinion about that patient on what type of assessment we might do or what type of treatment we we might offer them? Because unfortunately, the research shows that these aspects are affected negatively and health professionals spend less time with their patients with obesity and offer them less access to treatment.
Aileen: Coming to you Sarah, is there one thing that you would do to change the situation if you could?
Sarah: First of all just to back up what Grace said, I suppose being aware of checking our own behaviour, our own responses, challenging our own biases the way we've been brought up but also I think calling it out when we see it or making sure that if we hear our children or somebody say something that, you know, don't be that bystander. We used to say years ago in the classroom you knew it wasn't right, but you haven't the guts to stand up for somebody, I think if you can call it out that would be one thing.
On a professional level and if there are healthcare professionals and they feel that they would like to maybe consider being the expert, that person that helps change the narrative, you know, if they got in touch with yourselves perhaps to say hi, yep, I'm interested in perhaps being that presenter friend or that programme nutritionist or whatever, I'd like to give it a go as maybe get a few people together and organise some training, give it a go, see what we're like ourselves, you know, how do you take part in a programme sort of demystifying the media and the way it works and I think a collective of a pool of people that you could call on them would be very useful, and then you could support each other.
Aileen: Brilliant, and one final question for everybody, could I ask you if there's a book, a piece of research, films, story, art or even a person who has influenced your thinking around weight stigma and could you recommend that to our listeners? I might start with you Sarah.
Sarah: My goodness, actually when I knew that you were going to be asking this question and I did struggle with it. There's so many different things that came into my mind but I'm kind of going back to that being a 19 year old girl myself with probably not the healthiest relationship with food. I don't think there was anything majorly wrong but there was definitely an awareness of, you know, every calorie that I was eating and my then boyfriend at the time must have realised it was more of an issue than I thought it was and he bought me the Fat Is A Feminist Issue by Dr. Susie Orbach. And I remember being a little bit appalled that he bought me that but it was important. He said, I think you need to read this, I think that you're becoming too obsessed with your weight and your looks and I'm really glad that I read it because I thought you're you're right and I don't want to be calorie counting all my life, I don't want to live like this, so I think it was brave of him to do that but thoughtful as well and you know, it is a super book. And I know Susie Orbach is still writing about women and Bodies is her latest book I think and so yeah, that was an important read for me back in the day.
Aileen: Brilliant and the same question to you, Susie.
Susie: Yeah, like Sarah I struggled with that because there's people who've definitely influenced me through who I've met through ICPO and research. There's a lot of it there now, but there's one video that was released on World Obesity Day in March and it's on YouTube and it's called Ytisebo, It's actually obesity spelled backwards and it is powerful. It starts on just in a nutshell, you'd be better off watching it to get the full effect but basically, it shows people there's a few characters in it and they're showing stigma and then they have a realisation moment of what they were doing. I think I've had tears every time I've watched this, that's powerful. I would recommend anybody to go and look at it, I won't say any more about it because you need to watch it.
Aileen: And again for our listeners where possible we'll include links to these resources in our podcast information. Lastly to yourself, Grace.
Grace: So I've gone through the example of an experience rather than a book or film and a number of years back, when I was writing a grant for a piece of research looking at improving services for children and adolescents with obesity.
I was discussing the occupation with a senior colleague and I was told that I was immoral to be looking for funding for these children. And at the time, I was very upset and shocked, probably at the beginning because I took it as a personal insult initially, but I thought about those words many, many times since then, and I've tried to kind of break it down and try and understand why somebody who's in a very well respected position of power would feel that either the research wasn't valuable, which is, you know, fair enough or that the clinical service wasn't valued which I have more of a problem with, or that these children aren't worthy of being, you know, given the same access and I suppose that's the bit that time and time again, has got me more riled up, because I do believe that this is a human rights issue, it could be for children and adolescents, which is also compounded by the fact that often people with obesity are more likely to come from disadvantage, so the rates of obesity in those of disadvantage are higher.
So not only was a child potentially being discriminated against based on the shape of their body, but also then potentially a double burden of the fact that they may come from disadvantage, and I do believe that we do hold bias against the poor. And I use that term with the best intention and meaning, but I do believe there's a systematic bias against those who have less, and particularly potentially that's something perpetuated in the media as well.
So, for me that experience has been very valuable because it's made me think about why I want to work in this area, why I feel very committed about it, but how prevalent this bias is and how our health system and how quality improvement or research and the funding that goes with us can be swayed by people of influence in positions of power who may have a bias. And thankfully, there has been, over the last number of years, a little bit of an increase in funding for research in this area, but more often than not this is an area where if you want fame and glory, you'd certainly don't go into research in obesity. And the same in healthcare it's, you know, it's an area of us actually requires people to be very willing to think outside the box, to think about very complex systems and drivers of health and well being, but often it's not seen as a, you know, valuable area. Yeah, I think that that experience has really influenced me and it's one that will stay with me, I think for a long time.
Aileen: Thank you all for your diverse and profound explanations of those influences, really appreciate it and I really appreciate your input this afternoon on this podcast so thank you so much for taking part.
You've been listening to the safefood podcast.
Well, I think we'll end it there, thanks to all our guests Grace, Susie and Sarah for sharing their knowledge and experience.
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Until next time, goodbye and take care. ...