Ask the Expert Issue #1: Dr. Ximena Ramos Salas on Weight Bias and Discrimination

Our Ask an Expert series is your opportunity to engage with world-class obesity experts at Obesity Canada.  Each month, we will solicit questions for some of Canada’s top researchers and health professionals to answer. This month, it’s Dr. Ximena Ramos-Salas, Managing Director of Obesity Canada and a PhD in public health with a focus on weight bias and discrimination. Dr. Ramos Salas’s work with OC’s Everybody Matters Collaborative (a specialized national research and advocacy group) is a vital component to the development of equality for Canadians living with obesity. 

Q1: I have been discriminated against my whole life because of my weight.  It is so normal and acceptable to treat larger people differently. What will it take to change this norm? What can we do to protect ourselves?

Dr. Ramos Salas: Weight bias is pervasive in our society and most times it goes unchallenged by individuals, even by those affected by it. This is in part because weight bias is deeply ingrained in our social fabric.  

There are many factors that can increase weight bias among individuals, but a key driver is the belief that individuals have full control of their weight. In other words, we tend to think that a person develops obesity because they are lazy, stupid, unmotivated, and unable to just eat healthy and exercise. We therefore, make the incorrect assumption that obesity is the individual’s fault. The truth is that weight control goes beyond individual behaviours.

Research indicates that it is very difficult to change individual attitudes and beliefs about obesity. Some strategies to reduce weight bias include developing a broader understanding of the causes of obesity. In other words, rather than believing that weight is entirely controllable by eating healthy and exercising more, we must understand that obesity is caused by many factors, including genetics, psychosocial, and environmental factors.

Societal norms and stereotypes about obesity are based on a lack of understanding of obesity. I believe we need to change the societal narrative that obesity is self-inflicted.  Basically, we need to change the narrative that obesity is solely caused by overeating and inactivity. We must educate health professionals, policy makers, politicians, teachers, health insurance companies, and the general public about the complex drivers of obesity.

Research also shows that individuals with obesity have internalized weight bias. This means that individuals with obesity blame themselves for their disease. This makes it difficult for someone to stand up against weight bias and discrimination. Educating yourself about obesity is important so that you can change your own beliefs about obesity. A good place to start is the Obesity Canada website where you can find the latest science on obesity. As you become more aware of the causes of obesity, you can become an active agent in changing this negative obesity narrative in Canada. Protecting yourself against discrimination will require you to educate your health care providers, colleagues, teachers, and even friends and family members.

What can you do? Refer others to the Obesity Canada website, share our resources with them, and ask them to educate themselves about obesity before making assumptions and acting on those incorrect assumptions.

Q2: Every time I go to the doctor they seem to rush me out, barely look me in the eye and genuinely seem uncomfortable talking about my weight problems.  I haven’t gone to talk specifically about my weight but I do want help, desperately. How do we start that conversation without the doctor rolling their eyes and brushing it off?

Dr. Ramos Salas: Health professionals are not immune to the deeply ingrained societal weight bias and are often not trained in obesity management.  

Being aware of this is important for you as you build a therapeutic relation with your health care provider. In the health promotion field, we have a saying that goes like this: “we need to start where people are at”. This means that rather than making assumptions about what communities or individuals need or want, we must consider individual’s realities and contexts in which they live and work. As a patient, this means that you may need to do some investigative work before you embark in a therapeutic relation. For example, ask your doctor, nurse, dietitian, or fitness professional if they consider obesity to be a chronic disease? If they answer is no, you may need to either educate this person (guiding them to the Obesity Canada website for access to professional resources on obesity) or find someone else who shares this belief with you.  

Remember that most health professional do not receive training on obesity prevention and management as part of their education. This is why Obesity Canada offers training programs and other resources for health professionals.  You can find a list of publicly funded obesity management programs and obesity certified health professionals on the Obesity Canada website.

Finally, please remember that despite the Canadian Medical Association and the World Health Organization declaring obesity as a chronic disease, neither the Federal, Provincial, or Territorial governments have recognized obesity as a chronic disease. Obesity Canada is actively advocating for the recognition and treatment of obesity as a chronic disease. You can join our efforts by sharing your story with us and joining our efforts across the country.

Q3: Research indicates that individuals with obesity experience weight bias in healthcare, education, media and public policy sectors. In your opinion, where is weight bias the biggest problem in Canada and how can we fix it?

Dr. Ramos Salas: Examples of weight bias in health care include having a medical conditioned incorrectly attributed to one’s weight. Or when persons with obesity are denied preventive screening tests or health care access in general because of the lack of equipment in health care facilities (e.g. blood pressure cuffs that fit larger bodies) are also examples of weight bias.

In schools, studies have shown that teachers may have lower expectations from children with obesity or children who have larger bodies because of societal assumptions that individuals with obesity are lazy, unmotivated, and lack discipline. These lower expectations can result in lower educational outcomes for children which can impact their health and social wellbeing.

The media can also contribute to the perpetuation of weight bias attitudes and beliefs. For example, when the media glorifies a person’s weight loss and creates a narrative that weight loss is entirely possible and sustainable through diet and exercise alone. Although, there are some persons that can lose weight through diet and exercise alone, research indicates that long term weight loss maintenance through behavioural interventions is very challenging with relapsing rates that go above 90%. These media stories only fuel the narrative that obesity can be controlled through individual behaviours and thus drive further weight bias in society. Individuals with obesity need and deserve comprehensive and long-term support disease prevention and management strategies just like persons living with any other chronic disease including diabetes, cancer and heart disease.

However, one of the most common places where individuals with obesity experience weight bias is within their own family and friendship network. Considering the importance of family and friends for our health and social well being, this is a place where I believe we need to do a lot of work.  Examples of experiences of weight bias in our own social network include fat jokes that go unchallenged, weight- based teasing and bullying, comments of someone’s health because of their body size, or constant and unsolicited suggestions on how to lose weight. We all need to challenge these situations by educating our family and friends about the impact of weight bias and about the complexity of obesity as a chronic disease. We need to dispel the myth that weight is solely controllable through diet and exercise and that persons with obesity have done this to themselves. Telling our friends and family how these comments make us feel is important. Research shows that feeling shame and blame about our own bodies is detrimental to our health. Family members and friends need to understand that feeling bad about one’s body is an added stress and affects our health. Shaming and blaming does not change behaviours. The opposite is truth. We will often avoid health promoting behaviours for fear of being shamed and blamed for our weight and bodies.

Click here for our next Ask an Expert installment.

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