Learning Outcomes 1. Explain the concept of cognitive dissonance and how it influences our beliefs * 2. Define the terms related to weight stigma and explain each of their impacts * 3. Explain the link between weight and health 4, List 4 health behaviours found to decrease mortality rate * 5, Identify the the contexts in which weight stigma is experienced and how it appears in those contexts * 6 Identify the consequences of weight stigma on health and the four mechanisms through which weight stigma impacts health * 7. Identify the recommendations for decreasing weight stigma * 8 Compare and contrast the weight-normative approach to the weight-inclusive approach to health * 9 Identify the harms of the weight-normative approach and explain how the weight-inclusive approach addresses those harms. * 10. Explain what the weight inclusive approach looks like in practice and public health policy * 41 Describe the evidence supporting the weight-inclusive approach to healthcareCognitive Dissonance * People seek out information that is consistent with what they already know * Information that is inconsistent causes discomfort * To reduce this Reject our old belief Deny new evidence Rationalize our belief in light of new evidenceWhat is weight stigma?Weight Stigma (Brochu et al., 2018) Weight Prejudice Weight Weight Stigma Stereotypes Weight DiscriminationWeight Stigma Weight Stereotypes Beliefs about personal attributes and traits of people in larger bodies Weight Prejudice Negative attitudes and unfavourable evaluations of people in larger bodies Weight Discrimination Negative, unfair, or unequal behaviour or treatment of people in larger bodies because of their weight or sizeDo adults hold weight- biased beliefs?Weight Bias in Adults = Tiggemann & Rothblum, 1988 = Male and female students from Australia and Vermont asked about Weight related stereotypes Personal weight Dieting Body imageWeight Bias in Adults ™ Tiggemann & Rothblum, 1988 Findings ™ Vermont students had more negative body image than Australian students = Vermont students more likely to be dieting = Women overall more negative body image and more likely to be dieting . "And that their weight interfered with activities People with overweight BMIs viewed as = Warmer, friendlier, more unhappy, self-indulgent, and lazy "Less self-disciplined, self-confident, and attractive Weight stigma more pronounced = When judging a female individual = When the participant was female Weight stigma not impacted by weight of participantWeight Bias in Adults = Tiggemann & Rothblum, 1988 = Takeaways Women had lower body dissatisfaction and greater dieting behaviours Women are judged more harshly for weight Women judge others more harshly for their weight Judgements not influenced by participant weightWeight Bias in Adults Judged as less Active Intelligent Hardworking Successful Athletic PopularWhy does weight stigma exist?Why does weight stigma exist? Causal Attribution Theory Belief that weight within one's control Report more negative attitudes towards people in larger bodies Perceived violation of values (hard work and self-control Less likely to be stigmatized when weight seen as out of their control “What is beautiful is good” Our tendency to assign more positive characteristics and life outcomes to people we think are attractiveWeight Stigma Turned Inward Higher-body-weight people Weight stigma perpetuates * Often internalize stigma societal fear of fat * Report negative attitudes and * 60% of lower-body weight beliefs about larger bodies, people would rather give up including their own 1year than be heavy * 19% would give up 10 years or moreMatheson et al. 2012 + Followed 11,761 adults for an average of 14 years +» Nationally representative survey sample =~ PSN + Physical exam \ Extensive lifestyle, diet, and medical hx questionnaire pSay Matheson et al. 2012 + Life style behaviours Not smoking vat more servings of fruits and vegetables rN Ei = Exercising greater than 12 times a month aa) Moderate alcoholeu iy Healthy Lifestyle Habits and Mortality in Overweight and Obese Individuals Wace k mere) Cox Proportional Hazards Models for Risk of All-Cause Mortality for All Individuals Ages 21 and Older by Adherence to 0, 1, 2, 3, or 4 Healthy Habits Sample size = 11,761 unweighted (133,700, weighted) Number of Healthy Habits 1 3 4 and not smoking.Healthy Lifestyle Habits and Mortality in Overz Obese Individuals (vtatheson et al., 2012) Figure 1. Hazard ratio for all-cause mortality by body mass index (kg/m2) and numberof healthy habits (Ge, fruits and vegetable intake, tobacco, exercise, alcohol). Data from Table 3.Where and when is weight stigma experienced?Weight Stigma in Childhood Prefer not to play with overweight peers Assign negative characteristics to images of overweight people Commonly associated with teasing or being bullied Teased during physical activities Excluded from physical activities Verbally threatened Physically harassedWeight Stigma in Healthcare Physicians report preference for lower- body-weight people 74% of 15t year med students demonstrate implicit prejudice 67% also report explicit prejudice Physicians are less interested in treating higher-body weight patients Report beliefs that they are unattractive, noncompliant, and weak willedWeight Stigma in Healthcare * Physicians spend less time educating higher-body-weight patients Report less respect, prescribe different treatment * Half of higher-body-weight women report multiple occasions of stigma from physicians * Lower trust in healthcare providersWeight Stigma in Healthcare * Psychologists report lower expectations for patients with higher body weights Prognosis, effort, and functioning * More likely to set weight-related treatment goals “even when the patients did not report any weight concernsWeight Stigma in Employment * Higher-weight-body candidates are Ascribed more negative attributes More likely to be perceived as a poor fit Assigned lower started salaries (compared to thinner candidates with identical credentials) * Earn go cents for every dollar earned by lower-body-weight peopleWeight Stigma in Education * School teachers associate higher- body-weights with untidiness, decreased likelihood of success, and lack of willpower * Higher-weight-body adults receive fewer post-interview admission offers to graduate school * Same rate of interview offersWeight Stigma in Interpersonal Relationships * Family members 72% of higher-body-weight women reported weight stigma from family members * Friends 60% reported weight stigma from friends * Spouses 47% reported weight stigma from spouses Lower qualitied relationships and greater dissatisfaction with their relationshipsWeight Stigma in the Media Higher-body-weight people underrepresented on TV and depicted in stereotypical ways Media perpetuates weight stereotypes and reinforce negative attitudes After watching stigmatizing media, people report increased negative attitudes and increased desire for distance from larger bodiesWhat are the implications of weight stigma?Implications of weight stigma Behaviour changeImplications of weight stigma Health Perceived weight discrimination independently associated with increased mortality risk of 60% Weight stigma shortens life expectancy Weight stigma associated with depression, body dissatisfaction, and binge eating Weight based teasing is a significant risk factor for mental health disordersImplications of weight stigma Health Weight stigma associated with weight gain / weight maintenance at higher weight 2.5 x more likely to be a higher body weight 4 years later Or 3 x more likely to remain at one Weight teasing in childhood linked to weight gain in Longitudinal studies Independent of original BMI Being labeled “too fat" for girls at 14 predicted disordered eating at 19 More so if label came from family unger & Tomiyama, 2028)Internalized weight bias predicts weight regain, not weight loss maintenance.> (ch) \ Vf) i 7 ( } [ears cncemniesten “5 S. WN) 2 SO” é siecle) | disconnection / Se ~Implications of weight stigma Stress Weight discrimination associated with Increased inflammation Poorer glycemic control Higher blood pressure Increased cortisol (stress hormone) Shame increases cortisol secretionImplications of weight stigma Behaviour change Cortisol increases leptin and ghrelin Stimulate stress-induced eating Cortisol increases fat storage Weight stigma predicts disordered eating behaviours Diet pills, using laxatives, skipping meals, and binge eating Lead to increased weight gainImplications of weight stigma Behaviour change Internalized weight bias predicts decreased physical activity Desire to avoid stigmatizing situations Weight stigma increases desire to avoid physical activity Independent of BMI and body dissatisfactionImplications of weight stigma Healthcare utilization Barriers reported include Disrespectful treatment Negative attitudes Embarrassment at being weighed Unsolicited advice to lose weight Small gowns, exam tables, and equipmentImplications of weight stigma Healthcare utilization Stigmatization REuod mC) ecu] Micra avoidance Taek r-Ts\-re} WT MSe 40Implications of weight stigma Social Disconnection Higher-body-weight people have less social support Isolation increases health risk Social support decreases health riskIs weight stigma getting better? * Impact of weight bias on job-related outcomes decreasing since previous decades Increased awareness of biases and attempts to reduce their impactRecommendationsRecommendations Office environment Appropriately sized equipment and chairs Be aware of imaging in waiting room (magazines, art) Ask for permission to weigh, respect autonomy Focus Treat the whole person Consider referral question Training Include weight-sensitivity training in nursing, medical, dietetics, social work, counselling and psychologyRecommendations Language Person-first language Person with obesity Body weight descriptors Higher-body-weight people Fat Liberation Movement FatWeight-Inclusive HealthWeight-Normative Approach Emphasis on weight and weight loss Links weight with disease Emphasis on personal responsibility in weight Weight loss/management to prevent and treat health concernsWeight-Normative Approach * Evidence? \ Data do not support belief that higher BMI causes health problems - niin Yo Mortality risk Q y xX yerweight, “average” Underweight and \ weight BMIs Obese II BMIs g Obese | BMIsWeight-Normative Approach * Negative judgements Higher weight = unhealthy + societal burden Weight is controllable, linked to will power, and result of poor choices * Genetic and environmental factors more influential on weight than lifestyle choices * Public health messages “uninformed and unfair" * Focus on weight can create leaned helplessnessWeight-Normative Approach * Weight loss interventions fail * Weight loss attempts coincide with weight cycling Repeated weight loss and weight gain Higher mortality, loss of muscle tissue, hypertension, chronic, inflation, and cancers Strong links with higher mortality to the cycling itself Stable obese weight not linked with higher risk of mortality relative stable nonobese weight (rzehak et al. 2007)Weight-Normative Approach * Weight cycling linked with emotional distress * Weight cycling linked with increased weight gain, more binge eating, and less physical activity * Attempts to maintain weight loss increase risk for binge eating disorder and bulimia nervosa Related to the diet cycle * Encouraging weight loss in higher-weight patients likely to result in physical harmWeight-Normative Approach fe Perpetuates stigma by emphasising "good weights" and “bad weights" Weight stigma also experienced in lower-weight groups Harm in interpersonal relationships Misdiagnosing medical concerns Missing conditions often seen at higher weights Missing disordered eating behavioursWeight-Normative Approach * Stigma may partially explain what relationship exists between weight and health concerns Increased caloric consumption Increased likelihood of obesity long-term Elevated blood pressure Unhealthy weight control behaviours Binge eating behaviours Negative body image and low self-esteem DepressionWeight-Normative ApproachWeight- Normat HealthWeight-Inclusive Health * With access to nonstigmatizing healthcare, everyone is capable of achieving health and well-being, regardless of weight * Weight is not a behaviour * Behaviours: Eating nutritious good when hungry Stop eating when full Enjoyable physical activityWeight-Inclusive Health * Goals: 1. End the stigmatization of health problems (.e., healthism) 2. End weight-based discrimination, bias, and iatrogenic practicesWeight-Inclusive Health * 8principles: 1. Dono harm 2. Create practices and environments that are sustainable 3. Keep a process focus rather than end-goals for day-to- day quality of life 4. Incorporate evidence in designing interventions (where there is evidence)Weight-Inclusive Health * 8principles: 5. Include all bodies and lived experiences, create a norm of diversity 6. Increase access, opportunity, freedom, and social justice 7. Maintain a holistic focus because health is multidimensional 8, Trust that people (and bodies!) move toward greater health given access and opportunityWeight-Inclusive Health * What does it Look like in practice? Reframing body blame and shame to recognize the source Reframing beliefs that dissatisfaction motivates change Body shame is associated with reduced health behaviours Exploring connection between disordered eating and emotion regulation Broaden definitions of “beauty” and increase body appreciation Increase connection to body its internal cuesWeight-Inclusive Health * What does it look like in public health? Public health messages without weight focus More likely to encourage healthy behaviours Increased emphasis on healthy living Eliminating stigmatizing imagery and language Educate health workers about weight stigma and its consequencesBE 7 =, Health at Every ‘ — - Size (HAES) eae on EVERY BODY A Weight-Inclusive ModelDefinition ‘A model to support the health of people across the weight spectrum that challenges the current cultural ‘oppression of higher-weight people. Specifically, the model seeks to end (1) the stigmatizing of health problems (healthism) and (2) weight-based discrimination, bias, and iatrogenic practices within healthcare and other health-related industries as well as other areas of life. The model acknowledges that weight is not a behavior or personal choice and that normal human bodies come in a wide range of weights and seeks alternatives to the overwhelmingly futile and harmful practice of pursuing weight oss. 64,Health at Every Size (HAES) Factors other than weight are stronger for influencing people's health Holistic definition of health Includes absence of illness & presence of quality of life Health status should not be used to judge or oppress Pursue empirically supported interventions that promote physical and psychological healthHealth at Every Size (HAES) * Recommendations Intuitive eating Listening to body's cues Pleasurable movement Movement that you enjoy (not tied to weight loss goals) “Being compliant or rebellious about pursuing weight loss is replaced by a return to a process that honors the body's physiological signals of hunger, satiety, and need for movement.” 66Weight-Inclusive Health » Where's the evidence? Compared to weight-normative approaches, HAES programs were more successful in (Bacon & Aphramor, 2012): Physiological health improvements (eg. blood pressure, LDL cholesterol) Psychological health improvements (eg.. self-esteem and disordered eating) Lower dropout rates (more sustainable) No adverse outcomesReferences & 4 Bacon. L. & Aphramor. L (2019, Weight science: Evaluating the evidence for a paradiom shift. Nutrition Journal. 10, 9-9 doi101186/2475-2891-10-9 ‘Brochu. P. Peati.R. & Simontacchi L. (2018), Weight stigma and related social factors in psychological care. In S.Cassin. R. Hawa, & S Sockalingam (Eds), Psychological Care in Severe Obesity. A Practical and Integrated Approach (pp. 42-60) CCambridige: Cambridge University Press, dot10.1017/g781108241687.004 Hunger, J.M. & Tomiyama. A J (2018), Weight labeling and disordered eating among adolescent gis: Longitudinal evidence from the national heart, lung, and blood institute growth and health study. 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